Abstract
Objective
The aim of the study was to assess the effects of the maternal and child health (MCH) system strengthening through multilevel governmental collaboration in Nujiang Prefecture, China.
Study design
A case study design was applied.
Methods
Guided by the logical framework of the Nujiang MCH Comprehensive Intervention Project, national, provincial, and prefecture government sectors jointly implemented comprehensive health system strengthening (HSS) interventions in Nujiang Prefecture. In this case study, we conducted the end point surveys (November 2015 and January 2016) with 33 local MCH facilities. We also interviewed 35 MCH providers, government officials, leaders of MCH facilities, and project specialists. The thematic framework method was used to analyze the interview data, and descriptive analysis was performed to analyze the survey data.
Results
The three levels of governmental collaboration contributed to increased government investment in the local MCH system and ensured the successful implementation of the project. Participatory training methods and appropriate HSS interventions tailored to the local context were crucial to improve MCH providers' knowledge and skills, with the proportion of qualified MCH providers increasing from 70% in 2011 to 96% in 2015. Owing to this increase in knowledge and the increase in needed equipment, more MCH hospitals could provide inpatient obstetric services, and more town health clinics were capable of providing basic MCH services. The development of a reimbursement policy tailored to the local context promoted in-hospital delivery. At the conclusion of the project, percentages of antenatal care, in-hospital delivery, and newborn screening increased by 20.71%, 18.12%, and 278.62%, respectively. Growth monitoring coverage for children younger than three years remained stable at around 90%. However, the MCH system was negatively impacted by the workforce shortage. Those shortages were caused by a lack of positive recruitment and retention and incentive policies.
Conclusions
Implementation of comprehensive HSS interventions through multilevel governmental collaboration improves the MCH system in remote and low-income areas.
Keywords: Maternal and child health, Health system strengthening, Collaboration, Project evaluation, Low-income areas
Highlights
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Multilevel governmental collaboration improves the Maternal and Child Health (MCH) system in remote and low-income areas.
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Participatory training methods contributes to the positive effects of health system strengthening interventions.
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The MCH system is negatively impacted by the workforce shortages and inadequate incentives for health providers.
Introduction
In recent years, accessibility and quality of China's health services have improved continuously owing to the rapid development of its health system.1 However, disparities among various regional health systems remain, including the maternal and child health (MCH) system. The capacity of the MCH system is inadequate in many remote and low-income areas of China, which has led to the exacerbation of unmet health needs and subsequent health problems, such as maternal mortality and child malnutrition.2 A study on maternal mortality ratios in 2852 counties of China found that the 2015 maternal mortality ratio in Zanda County, Tibet, western China, was 830.5 per 100,000 live births, which is 38 times higher than the national average for that year.3 Some surveys on child nutrition have shown that the prevalence of stunting in remote and low-income areas of China has ranged from 17.8% to 25.8%, far exceeding the national average.2,4,5 A strong MCH system is fundamental to improving MCH outcomes. Therefore, there is an urgent need to improve MCH systems in remote and low-income areas, which commonly has been facilitated by implementing health system strengthening (HSS) interventions.6,7.
In remote and low-income areas, it is difficult for the local health sector to strengthen the MCH system owing to the limited workforce, facilities, equipment, and financial resources. Previous studies have shown that collaboration plays an important role in HSS;8 however, inadequate attention has been paid to the MCH system. Several studies have reported that successful collaboration among different levels of government can help improve the ability of local MCH facilities to collect and use data, develop MCH policies, provide quality midwifery services, and achieve MCH-related goals.9,10,11,12 However, these studies focused only on one specific element of the health system rather than multiple components, such as leadership and governance, service delivery, health workforce, health financing, medical products, and health information. Moreover, none of those studies focused on remote and low-income areas. To fill the gap in this area of focus, there is an urgent need to undertake research to examine whether and how collaboration between multiple levels of the government can improve the MCH system in remote and low-income areas.
Nujiang Prefecture in Yunnan Province of southwest China is a remote, low-income area where the natural environment is challenging, and MCH outcomes are the worst in the country. From 2012 to 2015, three levels of the government sector (MCH Department of the National Health Commission, Yunnan Provincial Health Commission, and Nujiang Prefecture Government) jointly implemented the Nujiang MCH Comprehensive Intervention Project (hereafter, ‘Nujiang Project’) that focused on MCH system strengthening, health education, and provision of nutritional supplements.
As part of the Nujiang Project, this study aims to evaluate the effects of MCH system strengthening through multilevel governmental collaboration in Nujiang Prefecture. Using these findings, we advocate the experiences from Nujiang Prefecture be applied to similar remote and low-income areas to develop their MCH systems and improve health outcomes.
Methods
Study design
Based on the theory of change and child health intervention theories, we developed the logical framework of the Nujiang Project, consisting of four components: background, activities, outputs, and outcomes. Guided by this framework, three levels of the government sector jointly implemented the project. Based on the findings of the project demand analysis,2 comprehensive HSS interventions, including health workforce training, establishment of a newborn screening network, equipment allocation, and policy making, were developed and implemented in four counties in Nujiang Prefecture (Lushui County, Fugong County, Gongshan County, and Lanping County) from September 2012 to October 2015.
In this study, we used a case study design to assess the effects of comprehensive HSS interventions on the MCH system in Nujiang Prefecture. In November 2015 and January 2016, we conducted end point surveys to collect detailed information on the project implementation process, changes in the MCH system and their associated reasons, and bottlenecks or constraints of the MCH system.
Evaluation framework
We developed the evaluation framework based on the health system theory recommended by the World Health Organization and the HSS experience of Nujiang Prefecture.13 The framework consisted of five components: investment, personnel, service, equipment, and leadership/governance. ‘Investment’ was related to the government's investment in the MCH system in remote and low-income areas. ‘Personnel’ referred to the local MCH providers' knowledge and skills. ‘Service’ was related to the provision (measured by the ‘coverage rate’) of MCH services. ‘Equipment’ referred to the number and usage of equipment in MCH facilities. Finally, ‘leadership/governance’ referred to the organization and implementation of the project, the health administrators' capacity to make MCH policies, and the effects and shortcomings of the MCH policies.
Data collection
The data sources of this study included interviews, surveys, and relevant policy documents and data. Multiple data sources helped ensure the internal consistency and reliability of this study.
The qualitative interviews took place in November 2015. Based on individuals' availability and recommendations from the local health sector, we recruited 15 health providers from seven prefecture/county/town/village MCH facilities. We divided these health providers into two groups. Each group discussion lasted about 2 h. The discussion focused on health providers' experiences, attitudes, and perceived benefits gained from the MCH system–strengthening activities. Based on the principle of theoretical saturation,14 we also conducted in-depth interviews with 20 individuals, including five government officials from Nujiang Prefecture and some counties, nine leaders of MCH facilities, and six national/provincial health specialists responsible for project supervision and training. In these in-depth interviews, we explored MCH investment and policy as well as participants' perspectives on the effects of the project, bottlenecks of the MCH system, and their recommendations for improvement. Each in-depth interview lasted about 1 h. Two professional interviewers with knowledge and skills of qualitative research conducted the interviews together.
In November 2015 and January 2016, we conducted end point surveys (after the intervention). We used the same method and questionnaires from the baseline survey (May and June 2012) to collect data from all local MCH facilities (n = 33) including the Prefecture MCH hospital (n = 1), county MCH hospitals (n = 4), and town health clinics (n = 28). The surveys from MCH hospitals mainly collected information on the number and quality of MCH providers and the coverage of main MCH services throughout the prefecture or county. The surveys from town health clinics mainly collected information on the provision of MCH services and equipment allocation.
In January 2016, we also collected policy documents, statistical monitoring data, self-evaluation reports, and publications from Nujiang Prefecture and its four counties.
Data analysis
We performed thematic framework analysis to analyze the interview data. Two professional researchers transcribed all audio recordings verbatim. The interview transcripts were the major data source, while notes taken during the interviews provided additional data. Based on the research objectives and evaluation framework, we identified five research themes: investment, personnel, service, equipment, and leadership/governance. For each theme, we generated codes using words, sentences, and passages. We also labeled quotes relevant to the codes and/or themes and selected the ‘best’ quotes to support our findings as reported in the Results section.
For the quantitative data, we performed descriptive analysis to compare the output indicators measured before and after the MCH system–strengthening activities. These indicators included the following: number and density of MCH providers, proportion of qualified MCH providers, number of town health clinics that provided basic MCH services, coverage of antenatal care for at least five visits, percentage of in-hospital delivery, growth monitoring coverage for children younger than three years, and rate of newborn screening. We used EpiData (version 3.0) to input data and SAS (version 9.2) to analyze the data.
Results
MCH investment
The collaboration between the three levels of government contributed to increased government investment in the local MCH system. According to policy documents and data, government investment in the MCH system mainly includes financial subsidies and special investments. Owing to the limited fiscal revenue of local government, financial subsidies to the MCH system were relatively insufficient and unable to meet the needs of health services. Special funds for national basic and major public health projects and the Yunnan Province MCH Project have become important sources of investment in the MCH system. An important feature of the Nujiang Project is the integration of existing special funding. According to the Nujiang Project Plan jointly formulated by the three levels of government, the MCH Department of the National Health Commission and the Health Commission of Yunnan Province should ‘set up policy priorities and provide funding support for Nujiang Prefecture to implement the project.’
During the implementation of the project, the two key aforementioned government sectors fulfilled their responsibilities to support Nujiang Prefecture to strengthen the MCH system. The MCH Department of the National Health Commission included Nujiang Prefecture in the National Newborn Screening Project supported the local health sector in establishing a network for newborn screening. Moreover, the MCH Department of the National Health Commission provided financial support for teacher training, expert supervision, and evaluation. In the meantime, the Health Commission of Yunnan Province selected Nujiang Prefecture as a target area for the Yunnan Province MCH Project. This enabled local MCH providers to receive on-site assistance from provincial health experts and attend on-the-job training at the provincial or national hospitals. Local administrators believed that the three levels of governmental collaboration played a pivotal role in contributing to the development of the MCH system.
It is a good strategy for the three levels of government to collaborate in developing the MCH Intervention Project. Such multilevel governmental collaboration has led to the MCH Department of the National Health Commission and the Health Commission of Yunnan Province paying great attention and providing support to Nujiang. (No.1 prefecture administrator)
MCH personnel
In general, the knowledge and skills of MCH providers improved. In this study, MCH workforce training included annual training by national and provincial experts in Nujiang Prefecture, short-term on-the-job training in higher medical institutions of Yunnan Province, and on-site specialist assistance across the county. Considering the relatively low educational level of local MCH providers, the participatory training methods were adopted, and the training course was focused on basic MCH services such as antenatal care, obstetric services, newborn screening, and child growth monitoring. Most interviewees (68%) believed that the trainings were beneficial, enabling local MCH providers to improve professional knowledge. Interviewees also indicated that local MCH providers were more confident in providing MCH services after attending the trainings. The survey data showed that proportion of qualified MCH providers increased from 70% in 2011 to 96% in 2015.
I worked in a national MCH center for three months, through which I advanced my skills. It is really useful for me to understand some basic concepts that were not clear to me in the past. In addition, I can learn about the experiences of other areas. What I have learned can be applied well in my work. (No.5 MCH provider)
The clinical skills of our MCH providers improved greatly and we are able to provide obstetric services with the help of on-site health experts from the provincial MCH hospital. (No.4 leader of a county MCH hospital)
Traditional training has little effect (on improving MCH outcomes) because of the complex content and knowledge….Over the past two years, changes in the training content have shown positive effects. After attending the training, health providers at the county and town health clinics are able to provide obstetric services, while in the past, they could not do that. (No.1 prefecture health administrator)
According to the interviews, we found that innovative training methods were important to ensure the effectiveness of the intervention. The interviewees were satisfied with the participatory training first used in Nujiang Prefecture. They commented that these trainings were better than the traditional class or lecture-based, non-participatory trainings because the training courses were easy to understand and health providers were more enthusiastic to participate.
Participatory training is useful. MCH providers at many town clinics actively participated in the participatory training. It is better than the traditional training.... (No.1 leader of a county MCH hospital)
This training method is very good! It enables us to understand and accept the content more easily. (No.12 health provider)
The Nujiang Project's impact was limited by the challenges of MCH workforce shortage and inadequate incentives for health providers. Some leaders of MCH facilities stated that the workforce shortage made it very difficult to send MCH providers to attend the training. Many voiced that the workforce shortage was the main reason why some MCH facilities were unable to provide basic MCH services. Some interviewees mentioned that owing to the lack of MCH providers, two of five MCH hospitals could not provide inpatient obstetric services and only the prefecture MCH hospital could provide outpatient pediatric services. The quantitative survey data also demonstrated the workforce shortage problem. During the implementation of the project, the total number of MCH providers in Nujiang Prefecture only increased by 5.09%, whereas the number of MCH providers per 1000 population decreased by 2.38%. In addition, some interviewees expressed that MCH providers lacked motivation to attend the training owing to the inadequate incentives. Specifically, MCH providers received the same income after the training as before the training, which did not match their increased skills, knowledge, and workload.
The limitation (of the training) lies in the lack of staff...We find it difficult to select staff to attend the training and our staff are not motivated to attend the training due to the lack of incentives. There is no (income) difference for staff who attend the training or not, or undertake more or less work. (No.1 leader of the prefecture MCH hospital)
There is a general shortage of MCH providers in Nujiang Prefecture...Two MCH hospitals cannot provide inpatient MCH services and only the prefecture MCH hospital has the capacity to provide outpatient pediatric services. (No.1 prefecture health administrator)
MCH services
The provision of MCH services in Nujiang Prefecture improved. Nujiang Prefecture includes one prefecture and four county MCH hospitals. The interview data showed that the number of MCH hospitals providing inpatient obstetric services increased from two to three. The survey data indicated that the number of town health clinics providing basic MCH services also increased. In addition, the rate of newborn screening for metabolic diseases, percentage of in-hospital delivery, and coverage of antenatal care for at least five visits increased significantly from 2011 to 2015. During the same period, the growth monitoring coverage for children younger than three years remained around 90% (Table 1).
Table 1.
Coverage rates of basic MCH services in Nujiang Prefecture from 2011 to 2015.
| MCH service | Coverage ratea（%） |
Cumulative growth (%) |
||||
|---|---|---|---|---|---|---|
| 2011 | 2012 | 2013 | 2014 | 2015 | 2011–2015 | |
| In-hospital delivery | 79.46 | 86.85 | 90.83 | 93.61 | 95.92 | 20.71 |
| Antenatal care | 60.66 | 79.79 | 80.14 | 78.83 | 71.65 | 18.12 |
| Growth monitoring for children younger than three years | 89.26 | 96.57 | 90.14 | 90.09 | 89.89 | 0.71 |
| Newborn screening | Unknown | 21.00 | 63.89 | 77.30 | 79.51 | 278.62 |
MCH, maternal and child health.
Provision of MCH services was measured by the coverage rate, defined as the ratio between the number of people actually receiving a MCH service and the number of people eligible and entitled to receive a MCH service in a specific region.
Equipment of MCH services
Allocation of equipment for MCH facilities significantly improved. According to the needs of local MCH services, the equipment (see Table 2) for basic MCH services was determined and purchased. The data showed an increase in MCH hospital ownership of all surveyed equipment, except for the lever weight scale. Furthermore, of the 28 town health clinics surveyed, the number of clinics having at least four types of equipment increased significantly. Local health administrators attributed some of the project's positive effects on increasing MCH capacity to the appropriate allocation of equipment.
Many MCH facilities have purchased necessary medical equipment. We are very grateful to this project (for enabling this), and since its implementation, the service capacity of our MCH facilities has been enhanced. (No.1 prefecture health administrator)
Table 2.
Number of MCH facilities owning different types of equipment before and after MCH system strengthening.
| Equipment | MCH hospitals (n = 5) |
Town health clinicsa (n = 28) |
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|---|---|---|---|---|---|---|
| Baseline | End point | Change | Baseline | End point | Change | |
| Lever weight scale | 2 | 1 | −1 | 10 | 20 | 10 |
| Horizontal bed | 2 | 5 | 3 | 9 | 28 | 19 |
| Vertical height gauge | 1 | 4 | 3 | 13 | 24 | 11 |
| Tape measure | 3 | 4 | 1 | 22 | 28 | 6 |
| Neonatal resuscitation equipment | 2 | 3 | 1 | – | – | – |
| Automatic chemistry analyzer | 2 | 5 | 3 | – | – | – |
| Automatic microelement analyzer | 1 | 3 | 2 | – | – | – |
| Automatic blood instrument | 1 | 3 | 2 | – | – | – |
| Children overall quality tester | 1 | 3 | 2 | – | – | – |
| Fetal heart monitor | 3 | 5 | 2 | – | – | – |
| Full-field digital mammography system | 0 | 1 | 1 | – | – | – |
| Hearing screening instrument | 2 | 5 | 3 | – | – | – |
| Infant radiant warmer | 2 | 3 | 1 | – | – | – |
| Neonatal jaundice tester | 1 | 2 | 1 | – | – | – |
MCH, maternal and child health.
According to their needs of practical work, township health clinics were equipped with four types of equipment for child growth monitoring.
Owing to the expert supervision and the three levels of governmental collaboration, allocation of equipment to MCH facilities was optimized. For example, most of the equipment was allocated to the prefecture MCH hospital in the past, and insufficient attention was paid to the MCH facilities at the county/town/village level. Furthermore, some of the equipment was not used to the fullest potential. The Nujiang Project's group of experts identified these problems in 2013, and it provided feedback to the three levels of government. In response, the government collaborators exerted a joint effort to solve these problems by reallocating medical equipment that was unused or less often used among MCH facilities. By the end of 2015, most of the medical equipment had come into use.
MCH leadership/governance
To improve the MCH system effectively, the three levels of government jointly established a collaboration mechanism that clearly defined their respective responsibilities. They formulated the project implementation plan together; met regularly to discuss strategies for governmental coordination and project implementation; and established an expert group responsible for implementation, supervision, and evaluation of project activities. An important principle of the project was to involve local governmental sectors and MCH facilities in the entire process, from project design to implementation and evaluation. This not only ensured the feasibility and pertinence of the project plan but also greatly mobilized the enthusiasm of local personnel to participate in the project.
To enhance the capacity of local MCH administrators to make policies tailored to their local context, the Nujiang Project conducted policy making training. Through the interviews, we found that MCH administrators endorsed the content and methods of this participatory training. When interviewers asked about the policy formulated during the project, four interviewees mentioned the development of a reimbursement policy that provided living and transportation allowances for hospitalized pregnant women and their caregivers. Considering the community's challenges of poor public transport and low-income level, this policy was effective in promoting women to deliver in the hospital.
The training about contextualized policymaking has had a great effect and will benefit our future work. (No.4 leader of a county MCH hospital)
Every county has its own social reimbursement policies. For example, four counties provide living allowances ranging from ￥200 to ￥400 for each pregnant woman and one county provides 25 kilograms of rice. These policies are effective in increasing in-hospital deliveries and decreasing the under-five mortality rate. (No.1 leader of the prefecture MCH hospital)
Some interviewees revealed that the lack of positive staff recruitment and retention and incentive policies has led to workforce shortages.
Existing staff are leaving, while outsiders are unwilling to join our medical facility because of the poor income and working conditions. (No.2 prefecture health administrator)
Due to the lack of effective incentive policies, we cannot implement performance evaluations for our MCH providers. (No.1 leader of the prefecture MCH hospital)
Discussion
To assess how to develop effective MCH systems in remote and low-income areas, comprehensive HSS interventions were implemented in Nujiang Prefecture. These interventions targeted five key areas: investment, personnel, service, equipment, and leadership/governance. The interventions were undertaken through a unique top-down approach involving multilevel (national, provincial, and prefecture/city) governmental collaboration. As mentioned earlier, such a collaboration is complex and likely to meet challenges or conflicts.15,16 In our study, the collaboration of the national, provincial, and prefecture/city governments was successful. This was shown with the increased government investment in the local MCH system. The reason for successful collaboration includes two factors. First, the three levels of government shared a common goal to enhance the MCH system in Nujiang Prefecture, and they jointly established a collaboration mechanism that clarified their respective responsibilities. Second, the project plan was jointly developed by the three levels of government. Previous studies have found that stakeholders at the grassroots level that are not engaged in the project design may resist the implementation of the project.17 In our study, local governmental sectors and MCH facilities participated together in project design to ensure the successful implementation of the project.
Between 2011 and 2015, coverage of most MCH services in Nujiang Prefecture improved significantly. During this time, the rate of newborn screening nearly tripled, in part owing to the establishment of the newborn screening network and staff training. There was a remarkable increase in the percentage of in-hospital delivery, which was most likely due to the living and transportation allowances provided for hospitalized pregnant women and their caregivers. Previous studies conducted in low-income areas have shown that low household income is a factor preventing women from going to the hospital to deliver.18,19 Our study confirmed that a reimbursement policy incentivizes pregnant women to deliver in the hospital.20 Other reasons for the increased percentage of in-hospital delivery may be related to the expansion of obstetric services at the hospital, the improvement of health providers' knowledge and skills, and the increase of necessary medical equipment at many MCH facilities. However, the various factors affecting MCH coverage are complex. In addition to health system factors, there also are a wide range of social and environmental factors affecting MCH coverage, such as the natural environment, public transport, cultural differences, the population's education and income level, and other socio-economic factors.21,22 The MCH system–strengthening interventions in this study explain a component of the reasons for the change in MCH coverage.
The use of participatory training methods in remote and low-income areas enabled positive outcomes. Participatory training was widely used during the health education activities.23,24,25 Evidence suggests that participatory training is better than traditional training methods because it considers an individual's experiences and needs and emphasizes the trainer–trainee interaction. In our study, interviewees commented that the participatory training methods were easy to understand and accept, and these methods made MCH providers enthusiastic to participate in the training. From this experience, we support the use of participatory training, rather than the class or lecture-based training, for MCH providers with a relatively low educational level in remote and low-income areas.
Although the comprehensive HSS interventions improved the service capacity of the MCH system in Nujiang Prefecture, some MCH facilities were still incapable of providing some MCH services. For example, two of the five MCH hospitals could not provide inpatient obstetric services, and only the prefecture MCH hospital was able to provide outpatient pediatric services. Interviews suggested that the workforce shortage was the key barrier for the provision of some MCH services, and it caused many MCH providers to not attend the training. As a result, these providers lost the opportunity to improve their knowledge and skills, further limiting their ability to provide effective MCH services. In summary, workforce shortages significantly affect the service capacity of the MCH system. Possible solutions for this prominent issue include developing positive staff recruitment and retention and incentive policies, providing attractive salaries, and offering staff training opportunities through concerted efforts between national, provincial, and prefecture/city governments as well as local MCH facilities.
This study has a number of limitations. First, we adopted a mixed-methods approach to collect data on the changes of the MCH system, thus reporting bias related to quantitative data may be present because we relied on MCH facilities to complete the questionnaire. Recall bias may have occurred in the interviews because some questions were related to the implementation process of the project, which had happened in the past. Second, given the harsh natural environment, transportation challenges, local language restrictions, and limited human and financial resources for the project, we did not conduct interviews with women and caregivers receiving MCH services and could not explore the changes in service quality from the perspective of demand side. Finally, all interviews were conducted by two interviewers who were also members of the project team. Although these researchers were skillful interviewers and adhered to the project protocol, their opinions could have influenced interviewees' perceptions about the effects of the HSS interventions.
Conclusion
In conclusion, implementation of comprehensive HSS interventions through multilevel governmental collaboration improves the MCH system in remote and low-income areas. Innovative participatory training methods and appropriate HSS interventions tailored to local contexts contribute to the positive effects of HSS interventions. The participation of local governmental sectors and MCH facilities in project design is conducive to ensuring the successful implementation of the project. However, issues related to workforce shortages and the lack of positive workforce recruitment and retention and incentive policies are constant barriers that must be mitigated to enhance the development of MCH systems in remote and low-income areas.
Author statements
Acknowledgments
The authors thank all the participants of this study. The authors are grateful to relevant government sections and health facilities for the support and assistance.
Ethical approval
This study was approved by Institute of Medical Information and Library Human Research Ethics Committee (HREC) (ref. no. IMICAMS/02/19/HREC). All interviewees provided verbal consent to attend the interviews.
Funding
This study was funded in part by the World Health Organization (WHO) (grant number: WP-12-MCN-002387), the United Nations International Children's Emergency Fund (UNICEF China) (grant number: 2012-702-022-116), and the Chinese Academy of Medical Sciences (grant number: 2016-I2M-3-018).
Competing interests
None declared.
Author contributions
X.L., F.W., and L.W. contributed to study conception and design.
X.L., X.D., and Y.C. collected and analyzed the data.
X.L. drafted the first version of the manuscript.
X.L., F.W., and L.W. revised and reviewed the manuscript.
All authors approved the final manuscript.
Contributor Information
F. Wang, Email: wang.fang@imicams.ac.cn.
L. Wang, Email: linhong@chinawch.org.cn.
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