2004). In 1988, about 12% of the Chinese population lived in areas with universal permission to have a second child and a further 50% lived in provinces extending a second-child permit to peasant households under certain conditions, and by 2001 about 60% of the Chinese peasant population and about 5% of the urban population was eligible for second-child permits (Scharping 2003).

# **2.2 Health sector reform**

The second area of policy on which this paper focuses is a protracted period of health system reform which appears to have had important consequences for at least three dimensions of access to care, namely the price of healthcare, the quality of services, and the service mix.

In the public sector, there was evidence of rising user fees and out-of-pocket expenditures through the 1990s (World Bank 1997), possibly attributable to the introduction of hard budget ceilings (Hsiao 1995; Liu and Mills 2002), as well as declining insurance coverage and higher co-payments (Henderson et al. 1995; Akin, Dow and Lance 2004). In addition, government spending on preventive facilities (Liu 2004) and lower levels of service provision (Liu and Mills 2002) fell substantially. It is argued that these changes in health system financing had deleterious consequences for child health and nutritional status by increasing the delay in seeking treatment (Liu and Mills 2002), reducing the utilization of pre- and postnatal care (Anson 2004), and contributing to the fall in immunization coverage (Liu and Mills 2002). In addition, the emergence of unregulated private healthcare providers – another key feature of the reform – resulted in tremendous variation in the quality of care that is provided (Lim et al. 2004).

# **2.3 Descriptive evidence of policy change from the CHNS**

The policy changes described in sections 2.1 and 2.2 are supported by data from the CHNS: One plausible measure of the effect of the one child policy is the change in the percentage of onlychildren, i.e. the percentage of children under 12 years of age without siblings of (under the age of 18). The CHNS data show that, in the seven provinces considered in this study, there has been a sharp increase in the number of only-children under 12. In 2000, 42.8% of children were only-children compared to only 27.1% of children in 1991, equivalent to a 57.9% increase. However, not all spatial and temporal differences in the percentage of only-children can necessarily be attributed to the one child policy, which is why this paper does not claim to estimate the total effect of the one child policy on nutritional status, but rather the effect of being an only-child.

The description of trends in healthcare access and quality is also supported by the data. Financial access to healthcare facilities appears to have deteriorated between 1991 and 2000: the mean (real) price of a cold or influenza-related visit more than doubled from 3.8 yuan to 8.8 yuan. In addition, the full economic cost of accessing services increased: travel costs increased significantly from a mean of 0.05 real yuan in 1991 to 0.43 real yuan in 2000 – although rising costs may reflect increased use of motorized transport, rather than bicycles or walking. Travel time to the closest healthcare facility did not fall significantly between 1991 and 2000. On the other hand, to the extent that mean waiting time and the availability of medicines can be used as indicators of the quality of treatment available, there appear to have been some improvements. The mean waiting time to see a healthcare worker halved over the decade from a mean of 18 minutes down to 9 minutes, and while there was little change between 1991 and 1997, by 2000 there had been a statistically significant increase in the availability of medicine at facilities.

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