Children born in rural China are three to six times more likely to die before they turn 5 than those in the cities, a study found, highlighting the wide gulf in healthcare provision for the rich and poor in China.

Pneumonia, birth asphyxia, and pre-term birth complications were the leading causes of death in children under 5, the researchers said in a paper published on Friday in the Lancet.

Led by Igor Rudan at the Croatian Centre for Global Health in Split, Croatia, the researchers searched public databases containing information from 1990 to 2008, including 206 long-term studies on causes of death in children under 5.

According to the paper, child mortality rates dived 71 percent from 64.6 to 18.5 per 1,000 livebirths from 1990 to 2008, but the disparity between child health in the booming cities compared with the poor countryside remained stark.

“The progress towards reduction of the child mortality rate in China is strongly determined by the degree of socioeconomic development,” they wrote.

The Chinese government says it has been working to address this inequity since 2003, putting in place a modest healthcare insurance system that it hopes will help the poorest meet basic medical needs.

In 2009, Beijing launched a new reform, pledging $123 billion over the next three years to provide universal and affordable basic healthcare for its 1.3 billion population.

In an interview with Reuters last week, Chinese Health Minister Chen Zhu said the insurance programme has been extended to much of the population.

“Now we are a 1.33 billion-population, and 1.23 billion are covered. Some 100 million are not covered, these are migrants, elderly people and children in cities and people in small enterprises,” Chen said.

“I hope that next year, a part of these 100 million people who are still uninsured…. will be brought in.”

Under China’s “hukou” household registration system, hundreds of millions of migrants from the countryside are unable to obtain residency status that would give them access to healthcare, education or legal protection in the cities where they settle.

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HONG KONG (Reuters) -