Summary of the impact

Population research carried out by the University of Southampton in China, the world's most populous country, led to significant changes in the structure and delivery of a major United Nations Population Fund (UNFPA) programme, thereby ensuring improved access to quality reproductive health and family planning services for more than 750 million Chinese men and women. Southampton's research provided the evidence of the impact that the UN programme was having which enabled the UNFPA to secure sustained financial support from international stakeholders to continue its work in China. The evidence from the research also convinced the Chinese government to roll out the programme nationwide and to re-orient family planning provision in China towards informed choice.

Underpinning research

Twenty years after the Communist Party came into power in 1949 under Mao Zedong, the Chinese population rose to 820 million from 560 million, forcing millions into extreme poverty. In 1979, China introduced its family planning policy through which couples in urban areas were restricted to only one child, with some exemption for rural couples and ethnic minorities. The policy was rigorous and coercive, and families who disobeyed the regulations received tough financial penalties and social restraints. This administrative, top-down approach had a profound impact on an entire generation.

In 1994, the United Nations' International Conference on Population and Development adopted a new Programme of Action for the next 20 years. It placed the emphasis on "meeting the reproductive needs of individuals within the framework of universally recognised human rights standards instead of merely meeting demographic goals". In response, China took a historic step towards a new approach to reproductive health and family planning (RH/FP) that enabled people to make informed RH/FP choices through client-centred services, without any discrimination or influence from health authorities.

The Chinese government worked with the UN Population Fund (UNFPA) to implement a pilot programme to improve the Chinese people's access to quality client-centred RH/FP services. In 2002, European member states including the UK, insisted on a comprehensive evaluation before committing further resources and in January 2003, Sabu Padmadas, Professor of Demography and Global Health and Co-Director of the University's Centre for Global Health, Population, Poverty & Policy (GHP3), and James Brown, Professor of Sampling and Official Statistics (up to 2013), were invited to lead an independent evaluation of the impact of the UNFPA programme in China. The Southampton academics, with collaboration from the China Population and Development Research Centre (CPDRC), began with an evaluation of the Fourth Round of the UN's China programme (1998-2002) and later carried out evaluations for the Fifth (2003-2005) and Sixth (2006-2010) rounds. The researchers made a series of policy and programmatic recommendations to improve the provision of reproductive health and family planning services in China [3.1-3.6].

The research used a structured, innovative multi-method approach to gather evidence through statistically robust population surveys and field research in intervention areas and non-intervention sites across all 30 provinces, representing 21.4 million people. Qualitative research included face-to-face interviews, focus groups with service providers, provincial authorities and stakeholders at provincial and county level, and assessments of client-centred service outreach in local communities to assess how health professionals were communicating RH/FP options to the public.

The research identified gaps in service standards at the grassroots level that the UN and Chinese authorities could address in subsequent rounds of the programme [3.1]. Excessive use of pregnancy and maternity services revealed over-medicalisation of births, suggested by significant increase in Caesarean births from 24% to 60% particularly in lower-level township maternity hospitals [3.2]. Health providers had inadequate training for the delivery of care, including gender- based counselling and referral services, and there was inefficient service delivery due to a lack of coordination between Chinese government agencies [3.3-3.6].

References to the research

Selected Journal Publications

Selected official reports and fact sheets

Grants:

Padmadas, Sabu S. & Brown, James J. Population impact of the UNFPA Reproductive Health and Family Planning programme in 30 counties of China, Fourth (2002-03), £15,000 funded by UK- DFID, Fifth (2003-05), £79,250 funded by the UNFPA and Sixth (2006-2011), $175,000, UNFPA funded.

Details of the impact

The long-term relationship between the University of Southampton and the Chinese ministries has enabled Southampton's research to make a significant impact on a) Chinese health policies and delivery of services; b) practitioners, professional services and health systems; c) health and well- being of Chinese men and women and (d) funding policies of international donor agencies.

Impact on the Chinese government's reproductive health policies.

The Southampton-led evaluation of the UN pilot project in China reinforced its credibility and convinced the Chinese government to scale up, between 2008 and 2010, the informed choices model and roll it out across the country [5.1-5.2]. This policy was implemented by China's National Population and Family Planning Commission (NPFPC) and the Ministry of Health (MoH). The Deputy Director General of NPFPC wrote in 2013 that "the research [from Southampton] was crucial in facilitating a high-level policy dialogue which eventually led to expanding the informed choices model of RH/FP services at the national level ...In this context, the contributions from Southampton and CPDRC team have been exemplary and unique in not only generating quality scientific evidence but also taking a proactive role in influencing policy dialogue and programme interventions" [5.1].

Administrative changes in the structure of the FP programme. The Southampton research highlighted the need to integrate RH/FP services to improve efficiency and quality of care. This recommendation has had a significant impact on the decision to merge the NPFPC and MoH into the National Health and Family Planning Commission [5.2]. Brought to effect in March 2013, one of the key strategies of the newly formed ministry is to reduce the overlap and improve efficiency in RH/FP service provision. The UNFPA Representative in China commented in a letter in May 2013 that "the logic and justification for integrating the two systems were repeatedly stressed in the recommendations of the independent research reports produced by the University of Southampton and team in China. We believe that the integration of the Family Planning and the Health systems will enhance client-centred services and ensure better quality of care in delivering high quality reproductive health services for men and women in China" [5.2].

Impact on practice of service providers. Between 2008 and 2009, the NPFPC and the MoH revised the in-service training modules to include, for the first time, gender-based RH/FP information, counselling, referral and treatment services for HIV/AIDS and other STDs. Acting on recommendations made by the Southampton researchers, they amended post-abortion care guidelines to consider the individual RH/FP needs of women and couples to ensure better quality service provision without coercion or discrimination [5.1-5.2]. Enhanced training for grassroots FP service providers was instituted, so that they could more effectively communicate with women and couples. In a letter dated March 2013, the Deputy Director General of the NPFPC confirms the contribution of Southampton's research in changing protocols and staff training as follows: "...the research enabled us to identify areas for further intervention, and reviewing the protocols for gender-oriented service standards, staff training at different levels, referral services and treatment compliance" [5.1]. Similarly, Dr Arie Hoekman, in a letter dated May 2013, states, "We have been reassured by the research generated by the University of Southampton that expanding contraceptive choices through client-friendly services can positively influence individual reproductive health" [5.2].

Evidence collected by the research team in 2010 shows the benefit of this improved practice and a shift in attitudes among health providers. Compared to the earlier period in 2003, birth quotas in the 2010 evaluation had been removed in 85% of the counties studied and induced abortions fell by an average of 43% (and up to 60% in more economically developed regions) [3.6]. Knowledge of RH/FP had increased among men and women (including awareness of HIV/AIDS and STD transmission routes) [3.4, 3.6]. Contraceptive choice was enhanced and more women and couples were making family planning decisions without being influenced by health providers [3.4, 3.6, 5.1, 5.2].

Impact on health and wellbeing of individuals. The extension of the UN programme nation-wide, which was a direct result of the findings from the Southampton-led research, has meant that 754 million Chinese men and women of reproductive age (15-49) now have access to family planning methods of their choice without coercion or discrimination from service providers. The policy changes, implemented by Chinese government ministries, have improved the quality of life of millions of Chinese men and women in 30 different provinces. Their cumulative impact at population level is captured in the findings of the UNFPA China Sixth Country Programme (2006-2010) Quantitative Evaluation Report published in December 2011 (see 3.4). The evaluation also found that changes to the UN programme, as suggested by researchers' earlier recommendations, led to "a significant improvement in the overall quality of care in RH services over the intervention period" and "significant progress in client-centred quality FP service delivery." The evaluation also discovered greater HIV/STI knowledge and an increased number of youth-friendly services. Further recommendations from the earlier research to have a special focus on young people, gender and HIV prevention were adopted in the Sixth programme (2006-2010).

The shift towards client-centred RH/FP services enabled, in particular, young women and men to access RH/FP services, irrespective of age or marital status. Evidence of the impact at population level was seen from the Sixth programme (2006-2010) evaluation report, where rates of reported condom use among young married adults more than doubled and induced abortion rates fell significantly [3.4, 3.6]. Further recommendations made by the Southampton team to increase the use of youth friendly sexual and reproductive health services — especially among men who were reluctant to seek services — have been fed into the Seventh Country Programme (2010-2014) which focuses on sustainable population development polices [5.2].

Impact on funding policies of the international community. The Southampton-led evaluation of the earlier UN programmes gave the UN the credibility it required to reassure 10 European countries and Australia of the programme's effectiveness and led to the continuation of international funding for its work in China to the present date [5.2]. The UNFPA Representative in China, Dr Arie Hoekman, wrote in May 2013, "the research [led by the Southampton team] generated wider interest and facilitated a national level response across China. In addition, the donor countries and relevant stakeholders were convinced of the UN programme impact in China which led to subsequent funding of the Fifth and Sixth cycles of the country programme" [5.2]. The validity of the results from three successive evaluation rounds, underpinned by high quality data and scientific publications in peer-reviewed international journals, was instrumental in convincing the Chinese government to scale up the programme nationwide, using an informed choices model [5.1].

The research has had an impact beyond China. The tools developed by Southampton for the UN programme were replicated in a similar programme in North Korea, involving researchers from the China Population and Development Research Centre. In July 2012, a member of the UK Department for International Development's Health Advisory Committee, having read the Sixth Country Programme report, invited Padmadas to discuss the population impact of the UN programme in China in order to examine whether lessons from China could be adopted for the DFID RH/FP programmes in Africa, in countries such as Sierra Leone and Rwanda. In February 2013, Padmadas was invited by the All-Party Parliamentary Group on Population, Development and Reproductive Health to a dialogue on China's Family Planning and Reproductive Health and Rights with representatives from British Parliament and NGOs including the UNFPA.

Sources to corroborate the impact

5.1 Corroborating letter from the Deputy Director-General, Department of International Cooperation, National Population and Family Planning Commission of the People's Republic of China (dated 10 March 2013).

5.2 Corroborating statement dated 30 May 2013 from the UNFPA China Representative and Country Director, United Nations Population Fund (UNFPA).

Contacts who can provide corroborating statement:

5.3 Director General, China Population and Development Research Centre, Beijing, China;

5.4 Former Representative, UNFPA China and Country Director, UNFPA.