In conclusion, the improvements in equity in rural versus urban maternal and child mortality in China over the last decade appear linked to national initiatives in health security funding, hospital delivery subsidies and possibly infrastructure improvements and training of staff. We do not have evidence to suggest comparable improvements in mortality equity within provinces, but the decreasing equity in health funding allocations and persisting inequity in out-of-pocket payments and per capita allocations would infer the opposite.

# **4. The influence of public sector governance weaknesses on HSR implementation**

The weaknesses in equity and efficiency in public expenditure on health and other social services may be partly explained by weak incentive structures in the provincial and sub-provincial governments. Efficiency and particularly equity in public resource allocation have not been influential performance indicators for governments and service providers at sub-national levels. (38) Local government officials are not accountable for equity in local health outcomes and for equity and efficiency in public resource allocation. In this respect, health differs from education, where the achievement of universal 9-year compulsory education is subject to strict monitoring and performance evaluation at the local levels.

Introducing equity in health outcomes and public resource allocation at sub-national level has also been a challenge also in the development of the monitoring and evaluation framework for HSR implementation. As a result, provincial and sub-provincial governments may not have the incentives or capacity to comply with China’s HSR objectives. (39) (20) Surveys (39) (20) and insights offered by government officials interviewed for this analysis suggest that provincial, prefecture and municipal governments may partly withhold public resources originally targeted to counties, townships and villages in need. In particular, interviews have confirmed that beyond the earmarked transfers and selected nation-wide priorities, provincial and lower levels of governments favor spending “close to home”; that is, mainly in the provincial capital city and at the prefecture and municipal level. Transfers – even if targeting specific counties – are transmitted through provincial governments/autonomous regions/municipalities and prefectures/districts (as illustrated in figure 1) and would be disproportionately spent on urban development (mainly urban infrastructure), leaving a shortage of resources at the county level and below to spend on essential social services. (39) It is worth noting that weaknesses in sub-national public sector governance also complicate the enforcement of health-related laws, regulations and standards. For instance, although China passed a strict national food safety law and introduced a series of food safety standards in 2009, implementation of the law is poorly regulated, and food safety problems (such as the resurgence of melamine-contaminated dairy products in 2010) have persisted. Chinese media have also reported enforcement weaknesses in the areas of environmental, road, patient and drug and vaccine safety among others. Possible conflicts of interest at local level (such as local economic growth versus public health safety) are not systematically monitored and addressed.

Sub-national governments are yet to become truly accountable for local performance in the areas of regulatory and law enforcement, policy implementation and the financing and delivery of services, such as health care. Recently, the case of Shenmu County in Shaanxi province, where 8