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1
The Health of
The Health of
Migrant Children
Migrant Children
Phoebe Williams
Phoebe Williams
MSc
MSc
Global Health Science candidate
Global Health Science candidate
CUHK & The University of Oxford
CUHK & The University of Oxford
Personal Background
Personal Background
Interest in health:
Interest in health:
Meningococcal Meningitis (1997)
Meningococcal Meningitis (1997)
MBBS (
MBBS (
Hons
Hons
)
)
-
-
The University of Sydney
The University of Sydney
Interest in children:
Interest in children:
Therapist for children with autism (2002
Therapist for children with autism (2002
-
-
2004)
2004)
Interest in migration:
Interest in migration:
Link to development (B Com)
Link to development (B Com)
Link to psychology (B
Link to psychology (B
Psyc
Psyc
)
)
Travel through Africa, Europe, India, and work
Travel through Africa, Europe, India, and work
in the refugee clinic at The Children
in the refugee clinic at The Children
’
’
s Hospital
s Hospital
at
at
Westmead
Westmead
(Sydney University)
(Sydney University)
Migration
Migration
-
-
The Facts
The Facts
Migration is one of the defining global issues of
Migration is one of the defining global issues of
the 21st century
the 21st century
-
-
more people
more people
‘
‘
on the move
on the move
’
’
today than ever before in history
today than ever before in history
Currently 192m people live outside their place of
Currently 192m people live outside their place of
birth (3% of world population)
birth (3% of world population)
Current annual growth rate of migrants: 2.9%
Current annual growth rate of migrants: 2.9%
‘
‘
Migration is an essential and inevitable component of the
Migration is an essential and inevitable component of the
economic and social life of every State. Orderly and
economic and social life of every State. Orderly and
properly managed migration can be beneficial for both
properly managed migration can be beneficial for both
individuals and societies
individuals and societies
…
…
yet few countries manage
yet few countries manage
migration effectively
migration effectively
’
’
International
International
Organisation
Organisation
for Migration, 2009.
for Migration, 2009.
Overall Research
Overall Research
1.
1.
A Systematic Review on the Health of
A Systematic Review on the Health of
Migrant Children
Migrant Children
2.
2.
A research document addressing the
A research document addressing the
unique issue of the health of internal
unique issue of the health of internal
migrant children in China
migrant children in China
Systematic Review
Systematic Review
Study Protocol
Study Protocol
Population
Population
: Children aged 0
: Children aged 0
-
-
18yrs
18yrs
Intervention
Intervention
: Migration
: Migration
Outcome
Outcome
: Child Health
: Child Health
Study Types
Study Types
: Observational analytical
: Observational analytical
2
Systematic Review
Systematic Review
Methods
Methods
Search Strategy:
Search Strategy:
Searches conducted in
Searches conducted in
Pubmed
Pubmed
,
,
Embase
Embase
,
,
Global Health,
Global Health,
Psycinfo
Psycinfo
& The Cochrane
& The Cochrane
library database
library database
Studies published 1999
Studies published 1999
-
-
2009
2009
English only
English only
Search Strategy
Search Strategy
Key words &
Key words &
MeSH
MeSH
headings (italics)
headings (italics)
used in literature search:
used in literature search:
Child health
Mental Health
Psychosocial Factors
Socioeconomic Factors
Malnutrition
Health service utilisation
Drug use
Teenage Pregnancy
Vacc*
Immunis*
Immuniz*
Infectious Diseas*
Obes*
Stunt*
Migrant*
Migration
Migrants
Immigr*
Emmigr*
Child
Child*
Infant
Student
Adolescent
OutcomeInterventionPopulation
Supplementary Search Strategy:
Supplementary Search Strategy:
China Report
China Report
Grey literature: Conference proceedings,
Grey literature: Conference proceedings,
briefing papers, and reports
briefing papers, and reports
Newspaper articles
Newspaper articles
Discussions with key informants in major
Discussions with key informants in major
migrant cities in China
migrant cities in China
Google search engine
Google search engine
Conference proceedings
Conference proceedings
Systematic Review
Systematic Review
Inclusion Criteria:
Inclusion Criteria:
Observational studies which examine a health
Observational studies which examine a health
impact of migration on children (0
impact of migration on children (0
-
-
18yrs) in
18yrs) in
contrast to a
contrast to a
‘
‘
comparison
comparison
’
’
population
population
Exclusion Criteria:
Exclusion Criteria:
Languages other than English
Languages other than English
Research lacking a clear comparison group
Research lacking a clear comparison group
3
Anticipated Results Synthesis:
Anticipated Results Synthesis:
Systematic Review
Systematic Review
Review of study quality
Review of study quality
Report findings in a tabulated form, with a
Report findings in a tabulated form, with a
narrative synthesis
narrative synthesis
Numerous heterogeneous health outcomes
Numerous heterogeneous health outcomes
anticipated; which will be discussed separately
anticipated; which will be discussed separately
Where possible, a meta
Where possible, a meta
-
-
analysis will be
analysis will be
performed for sub
performed for sub
-
-
groups (with accompanying
groups (with accompanying
chi
chi
-
-
squared test for heterogeneity)
squared test for heterogeneity)
Generalised
Generalised
Findings to Date
Findings to Date
Almost all literature worldwide examines the effect of
Almost all literature worldwide examines the effect of
international migration,
international migration,
comparing
comparing
health outcomes to
health outcomes to
resident
resident
children (
children (
not
not
native children)
native children)
Migrant children face significant barriers in accessing health
Migrant children face significant barriers in accessing health
care systems
care systems
Compared to resident children, migrant children have:
Compared to resident children, migrant children have:
Lower
Lower
immunisation
immunisation
rates
rates
-
-
higher rates of infectious disease
higher rates of infectious disease
Lower rates of breast
Lower rates of breast
-
-
feeding
feeding
Increased prevalence of
Increased prevalence of
atopy
atopy
Increased prevalence of dental caries
Increased prevalence of dental caries
Increased prevalence of accidents and injuries
Increased prevalence of accidents and injuries
Increased prevalence of lead poisoning
Increased prevalence of lead poisoning
Poorer maternal and neonatal health outcomes & indices
Poorer maternal and neonatal health outcomes & indices
Higher rates of obesity; micronutrient deficiencies
Higher rates of obesity; micronutrient deficiencies
Higher rates of teenage pregnancy & abortion
Higher rates of teenage pregnancy & abortion
Higher rates of psychological ill
Higher rates of psychological ill
-
-
health: anxiety, depression, substance abuse,
health: anxiety, depression, substance abuse,
criminal
criminal
behaviour
behaviour
These effects diminish with time (degree of acculturation)
These effects diminish with time (degree of acculturation)
Part Two
Part Two
Internal Migration in China
Internal Migration in China
Internal Migration
Internal Migration
Can rural mothers or parents improve their
Can rural mothers or parents improve their
child
child
’
’
s survival by leaving their villages
s survival by leaving their villages
and settling in towns and cities
and settling in towns and cities
…
…
Where modern health and social services,
Where modern health and social services,
employment opportunities, housing, stable
employment opportunities, housing, stable
food supplies, and increased information
food supplies, and increased information
on child health care are more generally
on child health care are more generally
available?
available?
Internal Migration
Internal Migration
Or, does it increase the risk of health issues to both migrant
Or, does it increase the risk of health issues to both migrant
and urban children?
and urban children?
Do migrant families settle in crowded slums where basic
Do migrant families settle in crowded slums where basic
household facilities essential for good health are
household facilities essential for good health are
unavailable?
unavailable?
Are they vulnerable to new diseases; separated from their
Are they vulnerable to new diseases; separated from their
support network; unable to breast feed due to
support network; unable to breast feed due to
employment?
employment?
Does they bring new infectious diseases to the city which
Does they bring new infectious diseases to the city which
spread, and place increased demand on already
spread, and place increased demand on already
-
-
stretched
stretched
urban resources?
urban resources?
Types of
Types of
‘
‘
Child Migrants
Child Migrants
’
’
1.
1.
Those who accompany their families to
Those who accompany their families to
towns and cities
towns and cities
2.
2.
Those who are born after their parents
Those who are born after their parents
migrate (in the city)
migrate (in the city)
3.
3.
Left behind children
Left behind children
4
The impact of rural
The impact of rural
-
-
urban migration
urban migration
on child survival
on child survival
Brockerhoff
Brockerhoff
(1994)
(1994)
-
-
Research on 17 nations between 1986 and 1990 found:
Research on 17 nations between 1986 and 1990 found:
Risk of child mortality is
Risk of child mortality is
increased
increased
if:
if:
Single moves occur over great distances or long durations
Single moves occur over great distances or long durations
Migration is involuntary (
Migration is involuntary (
eg
eg
IDPs
IDPs
)
)
Children are exposed to new epidemiological environments
Children are exposed to new epidemiological environments
Child survival depends on:
Child survival depends on:
The conditions underlying migration; The reasons for the move;
The conditions underlying migration; The reasons for the move;
Intended duration of stay
Intended duration of stay
The
The
receptivity
receptivity
of existing urban populations and authorities
of existing urban populations and authorities
Migrants need to be able to achieve sufficient economic success
Migrants need to be able to achieve sufficient economic success
to
to
attain the modern housing facilities and access to effective hea
attain the modern housing facilities and access to effective hea
lth
lth
services that influence a child
services that influence a child
’
’
s survival changes
s survival changes
Overall,
Overall,
increased risk
increased risk
of mortality in short
of mortality in short
-
-
term
term
;
;
decreased risk
decreased risk
of child mortality over long
of child mortality over long
-
-
term
term
Main Determinants of Child Survival during
Main Determinants of Child Survival during
Rural
Rural
-
-
urban Migration
urban Migration
-Improved housing facilities and
structure
-Increased access to / use of modern
health services
-Increased disposable income
-Gradual adoption of modern
reproductive and child-rearing practices
-Access to social support networks
-Exposure to new diseases
-Language and cultural barriers
-Barriers to accessing housing, employment, health
services
-Psychological stress of adjustment
-Crowded living conditions
-Discrimination by local authorities in service provision
-Depleted savings (due to need to send remittances)
Post-Migration
-Postponement of marriage or child-
bearing in women
-Exposure to new disease
-Abrupt termination of breast-feeding or change in
intensity
-Temporary unavailability of health services, support
network, adequate shelter and nutrition
-Physical hardship of move
-Temporary loss of income
During Migration
-Maternal Schooling
-Occupational skills
-Wealth / income
-Loss of entitlement to basic needs (food, income,
shelter) (eg IDPs)
Pre-Migration
(Selection factors
of migrants in
rural areas)
Positive impactsNegative impactsStage of
Migration
The Unique Situation of China
The Unique Situation of China
Population: 1.3bn
Population <18yrs: 342m
Rapidly urbanising: 42% (projected 70% by 2050)
Migrant Population of 225m (2008):
“The World’s largest ever peacetime migration”
Increased from 26m (1988)
Estimated to reach 300m by 2015
Viewed as a ‘life stage’ (chuqu -“to go out”) between school and marriage
Almost all are of child-bearing age
Responsible for 16% of China’s total GDP growth
Migrant Children: 20m
‘Invisible’ children: lack of registration and access to social services
Left Behind Children: 20m
Where do internal migrants in
Where do internal migrants in
China come from?
China come from?
>10m people: Sichuan, Henan
>10m people: Sichuan, Henan
>5m: Anhui, Jiangsu, Shandong, Hubei,
>5m: Anhui, Jiangsu, Shandong, Hubei,
Hunan, Guangdong, Guangxi
Hunan, Guangdong, Guangxi
Where do they go to?
Where do they go to?
70% to the East
70% to the East
16% to the West
16% to the West
14% to the Centre
14% to the Centre
Huang Ping & Frank N.
Huang Ping & Frank N.
Pieke
Pieke
, 2003: China Migration Country Report.
, 2003: China Migration Country Report.
DFID Research Report, May 2003.
DFID Research Report, May 2003.
Drivers of
Drivers of
Internal Migration in China
Internal Migration in China
• Marked spatial inequality: Urban-rural income disparity
• Surplus agricultural labour
• Economic Reform:
• The disintegration of state-owned enterprises (SOEs) & emergence of private
enterprise with the marketisation of the economy
• Diversification from a previously largely agrarian economy
• Poverty Reduction:
•
•
Even more beneficial than international migration
Even more beneficial than international migration
•
•
Average US$545 per migrant sent to local communities through rem
Average US$545 per migrant sent to local communities through rem
ittances
ittances
per year
per year
•
•
An economy
An economy
characterised
characterised
as
as
capital scarce
capital scarce
but
but
labour
labour
abundant
abundant
5
Rural
Rural
-
-
urban income inequality
urban income inequality
Liu et al. (1999). Equity in Health & Health Care: The Chinese
Liu et al. (1999). Equity in Health & Health Care: The Chinese
Experience.
Experience.
Soc
Soc
Sci
Sci
Med 49, 1349
Med 49, 1349
-
-
56 (1999).
56 (1999).
The 1978 Economic Reforms
The 1978 Economic Reforms
(
(
Gaige
Gaige
Kaifang
Kaifang
-
-
reform and opening up to the outside world)
reform and opening up to the outside world)
Transition from central planning to a market economy
Transition from central planning to a market economy
Including the
Including the
marketisation
marketisation
of health care:
of health care:
Halt to state provision of medical insurance
Halt to state provision of medical insurance
Introduction of user fees
Introduction of user fees
Privisation
Privisation
of health care
of health care
Followed the Soviet Model of development: high priority on heavy
Followed the Soviet Model of development: high priority on heavy
industry to speed
industry to speed
industrialisation
industrialisation
Has resulted in remarkable economic growth (average 9%pa) which
Has resulted in remarkable economic growth (average 9%pa) which
has diminished poverty; yet gains have been highly inequitable
has diminished poverty; yet gains have been highly inequitable
Increased demand for industry & construction sectors in the citi
Increased demand for industry & construction sectors in the citi
es
es
As strict migration control was relaxed, there was incentive for
As strict migration control was relaxed, there was incentive for
surplus
surplus
rural population to migrate to cities to find work
rural population to migrate to cities to find work
Rural China Prior to the
Rural China Prior to the
Economic Reforms
Economic Reforms
Rural population had guaranteed access to land
Rural population had guaranteed access to land
(
(
organised
organised
into communes)
into communes)
-
-
no landless poor
no landless poor
Strong cooperative Medical System
Strong cooperative Medical System
The Economic Reforms resulted in:
The Economic Reforms resulted in:
The
The
decollectivisation
decollectivisation
of Agriculture: Emergence of the
of Agriculture: Emergence of the
Household Responsibility System
Household Responsibility System
: rural households
: rural households
given individual responsibility for agricultural production
given individual responsibility for agricultural production
(shift from communal production)
(shift from communal production)
Resulted in a vast surplus of rural
Resulted in a vast surplus of rural
labour
labour
Collapse of the Cooperative Medical Insurance
Collapse of the Cooperative Medical Insurance
The Unique Situation of China
The Unique Situation of China
The
The
Hukou
Hukou
(Household Registration System)
(Household Registration System)
Established 1950s:
Established 1950s:
To control rural to urban migration?
To control rural to urban migration?
Or as part of a larger system established to provide the state w
Or as part of a larger system established to provide the state w
ith
ith
means and information that can be used for securing social and
means and information that can be used for securing social and
political order?
political order?
Linked entitlements to food and services to place of
Linked entitlements to food and services to place of
residence
residence
Characterises
Characterises
citizens by two classifications:
citizens by two classifications:
1.
1.
Residential location
Residential location
2.
2.
Socioeconomic eligibility: Agricultural / Non
Socioeconomic eligibility: Agricultural / Non
-
-
Agricultural
Agricultural
The
The
Hukou
Hukou
Polarised
Polarised
rural and urban China:
rural and urban China:
Urban residents: Provided with state
Urban residents: Provided with state
-
-
provided employment,
provided employment,
benefits
benefits
Since 1984, the
Since 1984, the
hukou
hukou
has become more lenient to
has become more lenient to
encourage restricted, regulated, orderly rural
encourage restricted, regulated, orderly rural
labour
labour
migration
migration
However, it still plays an important role in defining
However, it still plays an important role in defining
entitlements to state aid and access to key services
entitlements to state aid and access to key services
(education and health care)
(education and health care)
Hukou
Hukou
transfer is (almost) impossible. Instead, a person
transfer is (almost) impossible. Instead, a person
staying outside their locality >3months must apply for
staying outside their locality >3months must apply for
temporary residence registration
temporary residence registration
The
The
Hukou
Hukou
The nation
The nation
’
’
s social welfare & health care systems are still
s social welfare & health care systems are still
based on the
based on the
hukou
hukou
Rural migrants and their children are unable to transfer
Rural migrants and their children are unable to transfer
their
their
hukou
hukou
status to cities, so therefore suffer from very
status to cities, so therefore suffer from very
limited access to social services, including health care
limited access to social services, including health care
Compounded by the known health risks associated with
Compounded by the known health risks associated with
migration, the result is poorer health outcomes in migrants
migration, the result is poorer health outcomes in migrants
and their children
and their children
China is unique in that:
China is unique in that:
It has the largest worldwide population of internal migrants
It has the largest worldwide population of internal migrants
Its rural and urban citizens, and their access to social service
Its rural and urban citizens, and their access to social service
s, are
s, are
divided by the
divided by the
hukou
hukou
6
The One Child Policy
The One Child Policy
Introduced in 1980s
Introduced in 1980s
Incentives, close monitoring and bureaucratic
Incentives, close monitoring and bureaucratic
system of pregnancy approval
system of pregnancy approval
Migrant communities, lacking household
Migrant communities, lacking household
registration in cities, often have more than one
registration in cities, often have more than one
child
child
Further disincentive for registration and accessing
Further disincentive for registration and accessing
social service schemes
social service schemes
Recent laws mandated by Central Government will
Recent laws mandated by Central Government will
result in increasing fines
result in increasing fines
Another unique issue to China
Another unique issue to China
Health Care Reforms
Health Care Reforms
1950
1950
-
-
1980: Universal access to affordable
1980: Universal access to affordable
health care
health care
Insurance schemes in place: LIS, GIS, collective
Insurance schemes in place: LIS, GIS, collective
responsibility in rural sector
responsibility in rural sector
As part of the economic reforms, health care
As part of the economic reforms, health care
financing was also revised:
financing was also revised:
Increased co
Increased co
-
-
payments
payments
Decline in insurance coverage
Decline in insurance coverage
Rapid increase in cost of health care
Rapid increase in cost of health care
The Result:
The Result:
Widening health gap between rural and urban
Widening health gap between rural and urban
residents
residents
Increased IMR inequality: between rural and urban
Increased IMR inequality: between rural and urban
areas rose from 1.67 (1981) to 2.93 (1993)
areas rose from 1.67 (1981) to 2.93 (1993)
Currently ranked 188th (/191) worldwide for health
Currently ranked 188th (/191) worldwide for health
equality
equality
China
China
’
’
s Achievements in Health
s Achievements in Health
Mid 20th Century:
Mid 20th Century:
“
“
Positive outlier
Positive outlier
”
”
on the Preston Curve
on the Preston Curve
Excellent public health services
Excellent public health services
Focus on preventative medicine
Focus on preventative medicine
Improvements in Child Health (U5MR):
Improvements in Child Health (U5MR):
118 per 1,000 (1970)
118 per 1,000 (1970)
45 per 1,000 (1990)
45 per 1,000 (1990)
22 per 1,000 (2007)
22 per 1,000 (2007)
Eggleston et al. (2008). From plan to market in the health sector: China’s experience.
Journal of Asian Economics, 19, 400-412.
Demographics & Living Circumstances
Demographics & Living Circumstances
Male: 66%; Female: 33%
Male: 66%; Female: 33%
Age composition:
Age composition:
70% are aged 16
70% are aged 16
-
-
35yrs
35yrs
Education level: majority have completed 9 years in school
Education level: majority have completed 9 years in school
Distribution by industry:
Distribution by industry:
‘
‘
The Three D
The Three D
’
’
s:
s:
Dirty, Dangerous, Degrading
Dirty, Dangerous, Degrading
’
’
30%: Manufacturing
30%: Manufacturing
23%: Construction
23%: Construction
18% Street vendors
18% Street vendors
13%: Social services
13%: Social services
8%: Food & restaurant business
8%: Food & restaurant business
82% work 7 days per week
82% work 7 days per week
33% work more than 11 hours per day
33% work more than 11 hours per day
Average wage: 780Y (58% of average wage of urban workers)
Average wage: 780Y (58% of average wage of urban workers)
Only 3% have medical insurance
Only 3% have medical insurance
45% have no bathroom or toilet in their urban home
45% have no bathroom or toilet in their urban home
Subject to intermittent government
Subject to intermittent government
‘
‘
cleaning up
cleaning up
’
’
campaigns (demolition)
campaigns (demolition)
The
The
Hukou
Hukou
Restricts Access to Health Care
Restricts Access to Health Care
‘If a little sick, they don’t go to the hospital or take medicine.
If very sick, they just go home.’
Almost all migrants lack health insurance
Almost all migrants lack health insurance
Even though cooperative insurance eligibility has been extended
Even though cooperative insurance eligibility has been extended
to temporary
to temporary
residents of Shanghai, the
residents of Shanghai, the
uninsurance
uninsurance
rate is significantly higher in temporary
rate is significantly higher in temporary
(66%)
(66%)
v
v
’
’
s
s
permanent (21%) child residents [ORL 5.85, 4.62
permanent (21%) child residents [ORL 5.85, 4.62
-
-
7.41]
7.41]
In cities in which migrants are not included in new health refor
In cities in which migrants are not included in new health refor
m programs,
m programs,
they lack insurance all
they lack insurance all
-
-
together
together
Must pay out
Must pay out
-
-
of
of
-
-
pocket for health care
pocket for health care
93% OPP;
93% OPP;
v
v
’
’
s
s
26% of local residents
26% of local residents
Consequently, migrants have:
Consequently, migrants have:
Higher rates of self
Higher rates of self
-
-
treatment
treatment
Less access to health information
Less access to health information
Compounded by the current technical inefficiency of China’s health care system
(over-diagnosis, over-treatment, escalating costs)
The Health of Migrants
The Health of Migrants
High rates of:
Benzene poisoning
Pneumoconiosis
Infectious disease (increased SARS prevalence; STIs)
Work-related injury: 12,000 accidents / year in Shenzhen
alone
Chronic Disease
Poor reproductive health:
MMR 3-7x higher than urban resident women
In Shanghai, 2/3 of all maternal deaths occur in migrant women
In Shanghai, 2/3 of all maternal deaths occur in migrant women
2x rate of stillbirth
2x rate of stillbirth
Lack of health knowledge
7
Impact on Migrant Children:
Impact on Migrant Children:
Lack of Education
Lack of Education
There are 7
There are 7
-
-
8m migrant children of school age
8m migrant children of school age
Estimated 1.8m are not in school
Estimated 1.8m are not in school
Restricted by a number of fees:
Restricted by a number of fees:
‘
‘
out
out
-
-
of
of
-
-
catchment
catchment
’
’
fees,
fees,
textbooks/miscellaneous
textbooks/miscellaneous
‘
‘
extras
extras
’
’
Central Government policy to waive fees, but local governments
Central Government policy to waive fees, but local governments
are given
are given
‘
‘
discretionary power
discretionary power
’
’
to decide whether to include
to decide whether to include
migrant children in mandated laws
migrant children in mandated laws
If fees are waived, many barriers are still in place
If fees are waived, many barriers are still in place
-
-
eg
eg
both
both
parents must have temporary resident cards
parents must have temporary resident cards
In 2003, local children in Shenzhen were paying as much as 3x
In 2003, local children in Shenzhen were paying as much as 3x
local children for their education 67% pay higher school fees th
local children for their education 67% pay higher school fees th
an
an
urban resident children
urban resident children
Continues the intergenerational cycle of poverty
Continues the intergenerational cycle of poverty
Significant discrimination: from teachers,
Significant discrimination: from teachers,
classmates
classmates
Migrant Children:
Migrant Children:
Health Consequences
Health Consequences
Lack of access to basic health care
Lack of access to basic health care
Forced into marginal activities such as rubbish
Forced into marginal activities such as rubbish
collecting
collecting
Higher rates of child
Higher rates of child
labour
labour
Higher CMR, IMR and MMR rates compared to
Higher CMR, IMR and MMR rates compared to
(urban) resident populations
(urban) resident populations
Shanghai:
Shanghai:
IMR (resident children): 2.9 per 1,000
IMR (resident children): 2.9 per 1,000
IMR (migrant children): 7 per 1,000
IMR (migrant children): 7 per 1,000
Live in highly polluted, unhygienic, crowded
Live in highly polluted, unhygienic, crowded
conditions
conditions
Poorer Health from
Poorer Health from
Conception
Conception
Migrant women have less prenatal care
Migrant women have less prenatal care
In Shanghai, 50% have 0
In Shanghai, 50% have 0
-
-
1 prenatal examination
1 prenatal examination
Compared to <5% of permanent residents
Compared to <5% of permanent residents
Higher rate of emergency C
Higher rate of emergency C
-
-
sections
sections
Less knowledge about post
Less knowledge about post
-
-
natal health care
natal health care
practices
practices
Multiple barriers limit maternal health access:
Multiple barriers limit maternal health access:
low education levels, lack of health insurance,
low education levels, lack of health insurance,
one child policy, lower income, lack of
one child policy, lower income, lack of
registration
registration
Migrant Children: Infectious Disease
Migrant Children: Infectious Disease
Significantly lower vaccination rates than national averages:
Guangdong province:
Only 51-71% of migrant children obtained rubeola vaccination
57 – 80% have BCG
51-74% have polio
Much higher occurrence rate of infectious diseases: in Guangdong, were migrants
make up <20% of population, they make up 53% of rubeola cases
• Wuhan (Hubei Province):
• Only 30% of migrant children have been properly vaccinated;
• 8% had never undertaken any vaccination
• Only 25% had regular health examinations
•
•
Shanghai (CDC data):
Shanghai (CDC data):
•
•
95% vaccination coverage in resident children
95% vaccination coverage in resident children
•
•
85% in migrant children
85% in migrant children
•
•
Measles: 50% of cases occur in migrant children
Measles: 50% of cases occur in migrant children
Liang, Z. et al. Migration and the well-being of children.
Chongqing CDC
Chongqing CDC
22% of local child population are migrants
22% of local child population are migrants
Migrant children constitute 52% of measles cases
Migrant children constitute 52% of measles cases
For
For
immunisation
immunisation
programs, an additional 20% of vaccines
programs, an additional 20% of vaccines
are now provided (despite lack of
are now provided (despite lack of
childrens
childrens
’
’
registration)
registration)
Children are all checked for
Children are all checked for
immunisation
immunisation
status on entering
status on entering
school
school
-
-
catch
catch
-
-
up programs for those missing any vaccines
up programs for those missing any vaccines
Challenges: Lack of funds; difficulties in maintaining records
Challenges: Lack of funds; difficulties in maintaining records
on a highly mobile population; lack of parental education and
on a highly mobile population; lack of parental education and
health knowledge
health knowledge
8
Action by the Government
Action by the Government
2006: Revision of the
2006: Revision of the
Law on Protection of Minors
Law on Protection of Minors
Regulations to ensure migrant children have access to education,
Regulations to ensure migrant children have access to education,
abolition
abolition
of non
of non
-
-
residential fees for migrant workers
residential fees for migrant workers
Relaxation of the
Relaxation of the
hukou
hukou
:
:
2002: Central government designated migrant workers as members o
2002: Central government designated migrant workers as members o
f
f
the working class, rather than (formerly) peasants
the working class, rather than (formerly) peasants
2003: Central government committed to:
2003: Central government committed to:
Abolish restrictions on rural
Abolish restrictions on rural
labourers
labourers
seeking urban employment
seeking urban employment
Improve the living conditions, health care and personal safety o
Improve the living conditions, health care and personal safety o
f migrants
f migrants
Provide access to education for children of migrant workers
Provide access to education for children of migrant workers
2007: Ministry of Public Security proposed to the central govern
2007: Ministry of Public Security proposed to the central govern
ment to
ment to
eliminate the
eliminate the
hukou
hukou
to allow freer migration, allowing citizens to change
to allow freer migration, allowing citizens to change
their registration
their registration
Some provinces (
Some provinces (
Hebei
Hebei
, Shandong,
, Shandong,
Lianing
Lianing
,
,
Guangzi
Guangzi
, Chongqing) and
, Chongqing) and
cities (Beijing,
cities (Beijing,
Shangai
Shangai
) have launched trial
) have launched trial
hukou
hukou
reforms
reforms
Shenzhen Residence Cards
Shenzhen Residence Cards
Launched 1st August 2008
Launched 1st August 2008
Aimed to reach 5m non
Aimed to reach 5m non
-
-
hukou
hukou
residents in the city
residents in the city
Allows for access to:
Allows for access to:
permits to HK / Macao,
permits to HK / Macao,
education access, social
education access, social
security, family planning
security, family planning
Aims to establish
Aims to establish
comprehensive
comprehensive
demographic information to
demographic information to
better serve and monitor
better serve and monitor
migrant population
migrant population
Health System Changes
Health System Changes
Alongside
Alongside
hukou
hukou
relaxation,
relaxation,
there are also reforms of the
there are also reforms of the
Chinese health system in place
Chinese health system in place
However, although
However, although
authorities have mandated
authorities have mandated
that enterprises should offer
that enterprises should offer
medical insurance to migrant
medical insurance to migrant
employees
employees
, in reality this does
, in reality this does
not happen:
not happen:
Approx. 5m workers in Shenzhen
Approx. 5m workers in Shenzhen
Only 1m receiving medical insurance
Only 1m receiving medical insurance
Local officials explicitly state that it is “not in their
interest to devote much effort towards protecting migrant
workers’ rights…if they did so, it would increase the
labour cost for the enterprises and foreign investors may
just move to where labour regulations are more lax”.
Positive Programs in Place
Positive Programs in Place
BEIJING:
BEIJING:
Largest population of migrants in China (~4m children)
Largest population of migrants in China (~4m children)
Dashila
Dashila
St Medical Centre: Offers free family
St Medical Centre: Offers free family
planning, reproductive health checks;
planning, reproductive health checks;
Children
Children
’
’
s Day (1st June each year): Free health
s Day (1st June each year): Free health
checks
checks
Health education seminars
Health education seminars
Liulichang
Liulichang
Health Centre:
Health Centre:
Half Price treatment for migrant workers
Half Price treatment for migrant workers
Zhejiang: Clinics established by fellow
Zhejiang: Clinics established by fellow
migrants
migrants
Government program: to increase MCH &
Government program: to increase MCH &
vaccinations
vaccinations
Positive Programs in Place
Positive Programs in Place
The Central Government is planning to mandate
The Central Government is planning to mandate
improved social services for migrants and their
improved social services for migrants and their
children
children
-
-
free infectious disease prevention,
free infectious disease prevention,
treatment; vaccinations; maternity care
treatment; vaccinations; maternity care
Two recent documents:
Two recent documents:
Medical Reform
Medical Reform
Consultation Paper
Consultation Paper
and the
and the
Draft Social
Draft Social
Insurance Law
Insurance Law
acknowledged the needs of
acknowledged the needs of
migrant workers
migrant workers
However,
However,
these services rely on
these services rely on
:
:
Migrants having
Migrants having
registered as temporary
registered as temporary
residents
residents
in their new cities (costly, time
in their new cities (costly, time
-
-
consuming, one
consuming, one
-
-
child policy issues)
child policy issues)
Migrants having sufficient
Migrants having sufficient
funds to pay for any
funds to pay for any
extra expenses
extra expenses
which may not be free despite
which may not be free despite
government mandates
government mandates
Many programs are
Many programs are
‘
‘
encouraged
encouraged
’
’
by the central
by the central
government but local governments / employers are
government but local governments / employers are
not mandated
not mandated
to provide services to migrants and
to provide services to migrants and
their children
their children
9
New Concerns & The Future
New Concerns & The Future
The Financial Crisis: 30m migrants have lost their jobs
The Financial Crisis: 30m migrants have lost their jobs
Has resulted in increasing number of children
Has resulted in increasing number of children
‘
‘
left behind
left behind
’
’
Sudden increase in demand for rural resources
Sudden increase in demand for rural resources
2008: Central government policies issued to assist:
2008: Central government policies issued to assist:
Local governments should assist returning migrants
Local governments should assist returning migrants
Urban governments must only assist
Urban governments must only assist
permanent residents
permanent residents
and
and
‘
‘
skilled migrants
skilled migrants
’
’
(re
(re
-
-
training opportunities, budget housing etc)
training opportunities, budget housing etc)
Therefore,
Therefore,
those families most at risk are left with little protection
those families most at risk are left with little protection
I
I
n Conclusion
n Conclusion
Internal migration is a unique phenomenon in China,
Internal migration is a unique phenomenon in China,
affecting millions of people and their children
affecting millions of people and their children
The children of internal migrants are particularly affected
The children of internal migrants are particularly affected
by:
by:
Lack of urban
Lack of urban
hukou
hukou
Restricted education
Restricted education
Restricted health care access
Restricted health care access
Discrimination by peers
Discrimination by peers
Being born outside the one child policy
Being born outside the one child policy
The psychological impact of being
The psychological impact of being
‘
‘
left behind
left behind
’
’
Several policy reforms must be mandated by the Central
Several policy reforms must be mandated by the Central
Government if this
Government if this
marginalised
marginalised
, and growing, population
, and growing, population
is to receive the equal
is to receive the equal
accses
accses
to basic human rights.
to basic human rights.
Thank you
Thank you
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