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for a myriad of sexual health problems. A broken rural health care system (health system reformis underway), the threat of sexually transmitted infectious diseases such as HIV/AIDS andresurgent syphilis, and ongoing and new forms of discrimination against women and girls arealso part of the current context. Governance issues, particularly unaccountable rural governanceand the lack of a real legal system for redress of injustices provide a limit to popular movements(e.g. civil society) challenging unpopular government policies. International pressure, especiallythrough the UN system, is therefore critical for holding the line on global standards. UNFPA hasin fact done this at considerable cost to the organization over the last 20 years.In this short case study, I will briefly review the major challenges facing China today in UNFPA’sthree mandated areas, review UNFPA’s six country programs since 1979 and offer anassessment of their most significant contributions, discuss the unique “place at the table” thatUNFPA has in China and the opportunities it presents, discuss developments within the UNsystem affecting UNFPA’s China work, highlight relevant aspects of the Chinese bureaucratic andpolitical system relevant to the work of UNFPA. I then offer recommendations on what UNFPAmight do in China in the next phase in its three mandated areas and beyond to support China’ssocial and economic development, including how to deal with the unfortunate consequences ofthe 30 year old One Child Policy, which despite its success in reducing births has generated anew set of challenges.Page 6 of 34

Methodology for this Case StudyUnlike the other case studies prepared for the Center for Global Development’s Working Groupon UNFPA’s Leadership Transition, the China case study is more of a “think piece” in which Ioffer my own views and recommendations for UNFPA’s work in China. I reviewed documentsdescribing the six country programs since 1979 (and the one planned for the next five years)along with recent articles and publications. As I was only able to obtain a limited number ofofficial documents, the descriptions of the country programs are brief and may not be complete.I also conducted interviews with a few stakeholders and individuals representing differentperspectives on the program: a former UNFPA staff person (anonymous), a former UNFPAadviser during CP (country program) 4 and current professor of development studies (SusanHolcombe), a representative of China’s National Population and Family Planning Commission(anonymous), a demographer trained during CP1 (Wang Feng), and a Swedish diplomat who wasthe former Swedish ambassador to China and former head of the Asia section of SIDA (BorjeLjunggren). I corresponded by email and met with the current UNFPA China Representative(Bernard Coquelin).I was delighted to be asked to do this case study. I was the first UNFPA international programofficer in China from 1980-84 and have lived in China for 11 years working on reproductivehealth, population, gender, health, and HIV/AIDS. I managed the projects in the first countryprogram and, towards the end of my term, prepared a “Needs Assessment” for the secondcountry program. As part of the first crew of a new UN office, we were forging a set ofrelationships with government counterparts who had just emerged from intense nationalisolation and little contact with the West. Many of those government officials remain colleaguestoday. I worked in the earlier noncontroversial days of UNFPA China, before the criticisms thathave dogged the organization since 1985 began. I returned to China in 1987 to do field researchfor my PhD in public health on the implementation of the family planning program (incollaboration with China’s State Family Planning Commission. I lived in China again from 1996 to2001 as the Ford Foundation’s Reproductive Health Program Officer, and have continued tospend a considerable amount of time in China conducting research and consulting onreproductive health, HIV/AIDS, and rural health system issues.My five years in China with the Ford Foundation provided an interesting perspective on the UNin China—on the one hand, the freedom to work with other partners besides government(especially academic researchers and civil society) made me acutely aware of the limitations ofthe UN system. On the other hand, I grew to appreciate the important influence the UN has inChina, both because of the perceived neutrality of the multilateral system, in which China is anactive participant, and because of the trusted partnership built over the last 30 years. UNFPAhas not bowed to U.S. pressure to quit work in China and this is deeply appreciated by theChinese leadership.Page 7 of 34

Major Challenges Facing China Today in the UNFPA’s ThreeMandated AreasPopulation and DevelopmentChina’s leading demographers (trained in CP1) have concluded that during much of the 1990sChina’s fertility level was below replacement level and its total fertility rate (TFR) has been atabout 1.5 children per couple since 2000.5 In ten of China’s 29 provinces and municipalities,fertility was 1.1 or below, a level that rivals the lowest fertility countries in the world.6 China’sOne Child Policy which began in 1979 has sped up a demographic transition that was underwaybefore it was put in place (TFR had dropped to about 2 from over 6 during the 1970s) and it isunlikely that fertility will bounce back if the policy is lifted. With the current trends, China’spopulation will halve in about 30 years. A number of recent surveys document that fertilitydesires are low and unlikely to change even if the policy is lifted—in urban areas and thedeveloped coastal regions, only children who marry only children are allowed to have twochildren but few choose to do so7.5Gu Baochang, Wang Feng, Guo Zhigang, and Zhang Erli, “China’s local and national fertility policy at theend of the twentieth century,” Population and Development Review. 33 (1): 129-147, 2007.6Gu Baochang, Wang Feng, Guo Zhigang, and Zhang Erli, “China’s local and national fertility policy at theend of the twentieth century,” Population and Development Review. 33 (1): 129-147, 2007.7Zheng Zhenzhen, Institute of Population and Labor Economics, Chinese Academy of Social Sciences,presentation at Harvard University and Population Association of America 2010 Annual meeting, DallasTX, “Below Replacement Fertility and Childbearing Intention, Findings from the Jiangsu Fertility Intentionand Behavior Survey” at “China’s One Child Policy after 30 years: Time for a Change?” (New England ChinaSeminar, Harvard University and PAA 2010 annual meeting, organized by Joan Kaufman), April 2010.Page 8 of 34

Decline in Annual Births8Decline in Annual BirthsSources: National Bureau of Statistics, ChinaHowever, China is a big country and national averages mask huge differences in birth rates anddesired fertility. In many poorer rural areas in China’s interior, border areas, and in places withlarge minority populations, fertility desires remain higher, especially for male offspring.However, the contribution of these areas to the overall picture is small, and does not offset thetrends in births overall.The consequences of the policy after 30 years of forced low fertility with high life expectancywill play out for generations. These include a distorted age structure—an increasing elderlypopulation proportional to new labor force entrants and a badly skewed sex ratio at birthfavoring males.8Wang Feng, “China’s Looming Demographic Crisis: Causes, Prospects, Policy Options”, PopulationAssociation of America 2010 Annual Meeting, Dallas TX, session on China’s One Child Policy after 30 Years:Time for a Change?” organized by Joan Kaufman.Page 9 of 34

China’s Age Pyramid for Shanghai9China’s economic growth in the last two decades of the twentieth century has benefited from afavorable young age structure. However, China now also has more than 140 million people aged60 and older, an elderly population that surpasses the total population of Japan, andapproximately the same as the total population of Bangladesh or Russia.10 The size of China’selderly population aged 60 and above will increase to 200 million by 2015, and to over 300million by 2030. The relative size of these two groups—the young and the old—will soonchange, in opposite directions. Even today, many of China’s primary schools are closing, somebeing transformed into homes for the elderly. Since 1978 the number of primary schoolstudents has shrunk by two thirds. The size of the total labor force aged 20 to 60 will plateau inthe next ten years, after which a decline will begin. The size of the young labor force, aged 20 to24, has already reached its peak and has started declining. In the next 10 years, by 2020, thenumber will be nearly 20 percent smaller, and in 20 years, by 2030, will be only two thirds ofwhat is it is now.11China’s life expectancy is high at 73.1. An increasing number of those elderly will be parents ofonly children. By current calculations, one third (140 million) of all Chinese households are onlychildren and by 2060, over half of Chinese women at age 60 will be the parent of an only child.9Wang Feng, “China’s Looming Demographic Crisis: Causes, Prospects, Policy Options”, PopulationAssociation of America 2010 Annual Meeting, Dallas TX, session on China’s One Child Policy after 30 Years:Time for a Change?” organized by Joan Kaufman.10Wang Feng and Andrew Mason, “Population aging in China: Challenges, opportunities, and institutions,”in Zhongwei Zhao and Fei Guo (eds.), Transition and Change: China’s Population at the Turn of theTwenty-First Century. Oxford University Press, 177-196, 2007.11Wang, Feng, "Can China Afford to Continue its One-Child Policy?" Asia Pacific Issues. No. 17. Honolulu:East-West Center. 2005.Page 10 of 34

The 4-2-1 problem (where four grandparents rely on support from one couple with only onechild to support them in turn), already a major complaint of urban couples, will only continue toget worse. Currently only a small number of urban workers and government officials arecovered by pensions. The pressure for pensions and social security type arrangements for theelderly will increase just as both the overall work force and the number of working children tosupport aged parents shrinks.New Labor Force Entrants (20-24) will Drop by Nearly 34 Percent in the Next 20 Years12The other significant impact of the One Child Policy is the skewed sex ratio at birth in favor ofmales. China has a long history of son preference, similar to a number of other countries in Asia(e.g. South Korea and India), but the 30 year old One Child Policy seriously exacerbated thispreference and has contributed to increasing prenatal diagnosis using ultrasound followed bysex selective abortion. While officially against the law, it is widely practiced throughout China.China’s last official inter-census survey in 2005 reported a national sex ratio at birth figure of120.5: 100 in favor of males but when examined by parity, the distortion reaches 143.2:100 forthe second birth and 156.4:100 for the third birth.12Wang Feng, “China’s Looming Demographic Crisis: Causes, Prospects, Policy Options” (revised),Population Association of America 2010 Annual Meeting, Dallas TX, session on China’s One Child Policyafter 30 Years: Time for a Change?” organized by Joan Kaufman.Page 11 of 34

Sex Ratio at Birth by birth order, 1.4151.9156.4145148.8143.2Sex 0.1117.3115110132.8129.4125.0107.1 108.4107.7105.4 106.5113.8110.3109.4105.010012345 Birth orderIn the few pilot sites (prefectures in Hubei and Gansu provinces) where two children areallowed, the sex ratios are closer to normal (104:100 in Gansu and 109:100 in Hubei).14Sex Ratio at Birth：2000－2004Jiuquan PrefectureGansu ProvinceYearTotal13Enshi PrefectureHubei Province1st Child2nd ChildTotal1st Child2nd 1041051091061146Source: For 1982: National Fertility Sample Survey ; For 1987-2005: China Population Censuses and 1 %5Population Sample Surveys.14Gu Baochang, “A Journey of Eight Years” – Study of China’s Fertility Policy (2001-2009), power pointpresentation at Harvard University seminar and PAA annual meeting , Dallas TX, session “China’s OneChild Policy after 30 Years: Time for a Change?,” April 2010 organized by Joan Kaufman.Page 12 of 34

Projected forward, there will be an excess of about 40 million men by 2040 and the effects arealready evident today. The future shortage of women will be stark and the demographic andsocietal implications of this are hard to predict. While much has been written about the “barebranches” phenomenon of wifeless men who might potentially create social upheaval or spreadsexually transmitted diseases by frequenting sex workers, a more likely scenario is that Chinesemen may increasingly seek wives from poorer parts of the region and that national boundarieswill not define the marriage market. Advising on how to reverse these trends, bringing inevidence and expertise from other countries in the region, should be high on the list of prioritiesfor UNFPA’s work on gender and development.Urbanization/MigrationChina has steadily urbanized since the economic reform period began in the 1980s andresidence requirements and population movement restrictions were relaxed. The urbanpopulation now accounts for about 50 percent of China’s 1.33 billion citizens and is expected togrow to 70 percent by 2035. China has more cities (160) of over 1 million inhabitants thananywhere in the world. When China’s 140-160 million rural economic migrants are added to thepicture, the percentage of people living in medium sized and big cities and using social servicesis probably much larger, even while their government entitlements to social services are linkedto their rural residences. These urban poor and disenfranchised citizens are likely to grow overtime and many have called for an end to the “hukou” or household registration system and ashift to a new system based on residence. The recent 2010 census has instituted newapproaches to count the number of people living outside their formal “hukou” and shouldprovide important evidence on the extent of this phenomenon.Reproductive Health Services (Family Planning, HIV/AIDS, STIs/RTIs, MaternalMortality)Contraceptive Coverage and ServicesChina has made progress in moving its family planning program from a top down“administrative” approach (e.g. enforced with little choice of contraceptives) to a programbased on a quality of care service delivery approach. However, without the removal of the OneChild Policy, reproductive rights, a central principle of the ICPD agenda, will not be achieved.Even while 30 years of exhortations to control population growth have convinced most citizensof the value and contribution of the policy, the family planning program remains unpopular andis perceived by most citizens as an intrusion in their personal and family lives and decisions.Given the fertility levels and trends noted previously, the restrictive birth policy, the mainconstraint on reproductive choice and voluntarism in determining desired family size, is nolonger needed. The governance approach associated with policy enforcement is a holdover ofPage 13 of 34

the “command style” of earlier eras and is out of date in today’s China. It is a major source ofopposition to local leaders, who still are required to enforce it, and has been associated withlocal corruption in the way the “social compensation fees” or taxes on out-of-plan births arecollected. Moreover, it limits the opportunity to utilize the family planning infrastructure formore integrated service provision as most citizens will avoid family planning service centersunless required to be there.Due to the policy and program, however, contraceptive prevalence is high, at 90 percent ofmarried couples using modern contraception, mainly intrauterine devices (IUDs) andsterilization. Prior to the quality of care family planning program reforms in China since ICPD,couples were required to use IUDs after the first birth and to accept sterilization after thesecond birth. In the years since ICPD, contraceptive choice has expanded and the quality ofcontraceptives has improved, along with counseling on methods and client choice. Programstargeting sexually active youth and migrants (there are 140 million economic migrants in China,many of them young women) have been expanded, but these remain only partially effective inreaching these important groups (youth and migrants) who often avoid the official service sitesbecause of either confidentiality concerns or in order to avoid birth restrictions. A majorproblem for contraceptive service delivery is the “hukou” or household registration systemdetermination of where services must be provided. For rural migrants living in cities, their“hukou” remains in their villages, along with their administrative records and birth registrationrequirements.HIV/AIDSChina’s HIV epidemic continues to expand, even while considered low by international standards(national prevalence is under 1 percent). The government and UNAIDS estimate that 740,000persons are HIV infected. However, there are some concentrated epidemics with much higherprevalence in parts of China and the epidemic is transitioning to a sexually transmitted one—7percent of all new infections in 200915, including among men who have sex with men (newinfections among men who have sex with men accounted for 32 percent of the total16). Evenwhile there is some uncertainty about the dynamics of the sexually transmitted epidemic17, it isclear that the percentage of women is increasing, from 19.4 percent in 2000 to 35% in 200818.15Zunyou Wu, Yu Wang, Roger Detels, Mary Jane Rotherham-Borus, “China AIDS Policy implementation:reversing the HIV/AIDS epidemic by 2015” International Journal of Epidemiology 2010: 39: ii1-ii316UNAIDS China, Key Data. Available at:www.unaids.org.cn/en/index/page.asp?id 178&class 2&classname Key Data.17These may be the wives of married gay men or returning male migrants, the sexual partners of IDUs,commercial or transactional sex workers, or youths with multiple or concurrent sexual partners.18UNAIDS China, Key Data. Available at:www.unaids.org.cn/en/index/page.asp?id 178&class 2&classname Key Data.Page 14 of 34

HIV services are provided mainly through China’s Centers for Disease Control system which hasbeen the main recipient of government and donor funding for HIV/AIDS prevention andtreatment, including substantial funding from the Global Fund for AIDS, TB and Malaria. Testingof pregnant women and prevention of mother to child transmission coverage has remained low,partly because of the poor integration of services with both the Ministry of Health’s Maternaland Child Health Services system and the family planning service system and the inability tosystematically reach unmarried youth seeking abortions. Condom use rates have increased inmany populations including sexually active youth and urban business men, but at the same timeboth formal and informal sex work has re-surged in China and entertainment venues wheresexual services are available are ubiquitous, even in rural cities and towns. Many of the big cityvenues are staffed by young migrant women (and men for men who have sex with men venues)who work for several years for e

China Case Study on UNFPA Country case study prepared for the Center for Global Development Working Group on UNFPA's Leadership Transition By Joan Kaufman, Sc.D. Distinguished Scientist, Heller School for Social Policy and Management Lecturer on Global Health and Social Medicine, Harvard Medical School kaufmanj@brandeis.edu March 2011