Changes of equality of medical service utilization in China between 1993 and 2018: findings from six waves of nationwide household interview survey

Remarkable socioeconomic changes have taken place in China in the last three decades. GDP per capita has increased from US $377 in 1993 to US $12,556 in 2021. The disposable income per capita has increased from US $331 in 1993 to US $5,157 in 2021 [1]. Proportion of people aged 65 years and over has increased from 5.9% in 1993 to 14.2% in 2021 [2]. The life expectancy at birth increased from 69 in 1990 to 78 in 2020 [2].

During the same period, China’s health system has experienced significant changes as well [3‐5]. Medical facilities and workforce for health have been developing rapidly. From 1993 to 2021, the number of hospitals increased from 15.4 thousands to 36.6 thousands, ward beds per 1000 population increased from 2.6 to 6.7, and the health professionals per 1000 population increased from 1.5 to 3.0 [6]. Mean while, the demand for health services is expanding and the prevalence of chronic diseases increased from 12.3% in 1993 to 34.3% in 2018 [7].

At the same time, the Chinese government started to restructure its health insurance system. Urban Employee Basic Medical Insurance (UEBMI) was established in 1998. New Rural Cooperative Medical Scheme (NRCMS) was launched in 2003 and achieved nearly universal coverage by the end of 2008. Urban Resident Basic Medical Insurance (URBMI) was established in 2007 and almost achieved universal coverage in 2010. Now China has the largest population covered by social health insurance in the world [8, 9]. The expansion of health insurance financing year by year and better financial protection played an important role in improving urban and rural residents’ affordability for health service and contributed to alleviating the problem of “seeing a doctor is expensive” [10‐12].

In addition to health insurance expansion, China initiated a new round of health care system reform in March, 2009, including improving benefits of basic health insurance, promoting coverage of basic public health services, drug supply and the regulatory system reform, public hospital reform, construction of primary health care facilities, and promotion of tiered healthcare delivery system. These reform initiatives have achieved substantial progress in terms of improving access to health service, health resource allocation and the equality in health care utilization [13‐15].

After decades of experiences with development of health system, crucial questions and widespread concern remain about the response to the reforms. It is critical to examine the trends in health care utilization and equality in the past 25 years that covering a series of health reforms, which could lead to a continuously comprehensive long term effect on health system. Even though most of the studies analyzed the change of health utilization in a short period (usually within five years) based on the data from healthcare provider [16‐18], the data of health service demand cannot be obtained directly, and the inpatient care utilization from the provider side is usually overestimated. In addition, a few of studies analyzed the health utilization before 2013 by using the data from the National Health Service Survey (NHSS) [19, 20]. However, the literature reveals a lack of studies describing a coherent, non-fragmented analysis of China’s health care utilization and equality from 1993 to 2018 covering a series of health reforms based on the data from demanding side.

Using data from the six waves of NHSS, this study aimed to investigate changes in healthcare utilization and its equality among the Chinese population between 1993 and 2018, during which time a series of health reforms were fully initiated. A secondary aim of this study was to conduct analysis of data comparing rate of health service use and access between urban and rural population, across regions and among income subgroups. Findings from the analysis could provide important information about the long-term progress of health care system reform on improving equality between urban and rural population, across regions and among income groups at different stages of health reform. In addition, the northeast was added in the region subgroups for regional equity analysis, which provides a more refined understanding of the regional differences of healthcare utilization and a new perspective of the changes in equality.

From 1993 to 2008, the probability of feeling sick within two weeks increased from 13.7% to 17.6% [7], while the outpatient healthcare utilization (the proportion of outpatient visits within last two weeks) showed a trend of slightly fluctuating decline, and the trends for urban and rural areas were similar with the overall trend. The NHSS data showed that from 1993 to 2008, the proportion of self-treatment increased from 20.1% to 35.7%, and the proportion of unmet treatment needs for the disease due to financial burden also increased from 33.5% to 38.2%, and declined to 27.1% and 29.2% in 2008 respectively. However, the outpatient healthcare utilization rate for the population with and without social health insurance also were similar with the overall trend, which dropped from 20.2% and 18.1% to 15.1% and 10.7%, respectively. It suggested that the social health insurance didn’t influence the outpatient healthcare utilization in this period. During this period, the health reforms can be divided into period of introducing market forces in health sector in 1990s with UEBMI established in 1998 and the period of starting restructure the medical insurance system from 2003 to 2008 with a pilot of NRCMS in 2003, and a pilot of URBMI in 2007. Actually, with economic development, allocation of market adjusting resources solved the problems of difficult access to doctors due to the shortage of medical resources. However, as a result, the lack of effective constraints on the rapidly growing supply of medical services, and in the initial stage of establishing a universal medical insurance system, with a not high level of financing and financial protect, NRCMS and URBMI mainly focusing on reimbursement for inpatient, finally increased barriers to outpatient healthcare utilization.

Our results showed that the outpatient healthcare utilization (the proportion of outpatient visits within two weeks) went up after 2008. The trend was consistent with the considerable rise of the probability of feeling sick within two weeks since 2008, which increased from 17.6% in 2008 to 33.4% in 2018. Major causes for visiting a doctor within two weeks were having cold (including acute nasopharyngitis, acute upper respiratory infection and influenza) and gastroenteritis in 1993, accounting for 48% of all visits, while hypertension and diabetes only accounted for 2.6% in the same period. The proportion of visiting a doctor within two weeks due to hypertension and diabetes increased year by year after 2003 and raised up significantly after 2008, increasing from 10.5% in 2008 to 25% in 2018. Hypertension and diabetes have become the second and third major disease for visiting a doctor following cold [13]. Trends in these increases between urban and rural areas were fairly similar, and the growth of the probability of feeling sick within two weeks in rural areas (with 16 percentage points growth) is higher than that in urban area (with 14 percentage points growth) from 2008 to 2018 [7]. In 2009, the National Basic Public Health Services Programme was implemented and hypertension, diabetes screening and management could be provided to all residents free of charge. As can be seen, the increases of outpatient healthcare utilization may largely benefit from the expansion of basic public health service and improved health management on chronic diseases since 2009 [26]. The basic public health service programme promotes the prevention and management of diseases, screens out more patients with chronic disease, which increase the demand for health services and expand the outpatient healthcare utilization. More importantly, it promotes the improvement of the accessibility of health services, making positive changes to healthcare utilization which is changed from ignorance of health condition and disease prevention, failure to diagnose and treatment, to concern about health.

Hospital admission rate increased from 2.6% in 1998 to 13.8% in 2018. The growth of age-standardized result reached to 9 percentage points, with 11 percentage points in rural area and 7 percentage points in urban area. This is a significant increase of respondent self-reported hospitalization. According to the data of the National Health Interview Survey in United States, the hospital stay in the past year decreased from 7.6% in 1998 to 7.3% in 2018 [27]. And the growth of hospital admission rate of hospital statistics data from 1998 to 2018 in Australia, Germany, Japan, the South Korea is about 2, 6, 3, 9 percentage points [28]. Compared with 2003, hospital admission rate in rural areas has a significant increase in 2008, with age-standardized annual growth rate of 13.6%. With the increase of income and availability increase of hospitalized service, it should be noted that the increase in hospital admission rate in rural areas is equivalent to the achievement of universal coverage of NRCMS in the same year and the rise of its financing level year by year [29]. The unmet need of hospital admission in urban and rural areas decreased significantly and the unmet healthcare needs due to financial burden exhibited a decline as well [13], falling from 18.3% (urban) and 24.5% (rural) in 1998 to 9.0% (urban) and 10.2% (rural) in 2018, respectively. The results showed a great consistency with the timeline of the establishment of NRCMS and URBMI, reflecting the role of social health insurance in increasing healthcare access in China [15, 30].

Why the annual hospitalization rate became higher for rural population than for urban population? In 1998, the inpatient reimbursement rate for urban and rural population was 55.9% and 9.6%, and cost for US $487.6 and $185.0 per admission, respectively. Since 2003, the NRCMS and URBMI for rural and urban areas has been successively established and the level of financing has increased year by year, then the reimbursement ratio for hospitalization expenses has also been continuously increased. In 2018, the inpatient reimbursement rate for urban and rural population reached about 57% and 53% [7], respectively. In particular, the inpatient reimbursement rate of URBMI and NRCMS increased from 35 and 26% in 2008 to 52% and 50% in 2018, significantly shrinking of differences with reimbursement rate of UEBMI. Moreover, NRCMS focuses on reimbursement for inpatient and catastrophic outpatient expenses, which to a certain extent encourages rural residents to have more inpatient services than outpatient services, and promote the large growth of inpatient care utilization for rual polulation. In addition, under the condition that the outpatient healthcare utilization for urban and rural residents in 2018 tended to be the same, the hospital admission rate of cold for rural residents in 2018 reached 11.6‰, which was much higher than that of urban residents (6.1‰), indicating that unnecessary hospitalization in rural areas may be over the city.

Aside from the northeast region, the gap of health care utilization between urban and rural areas and across regions and income groups has narrowed down and equality has been significantly improved. The utilization of both outpatient and inpatient care for rural residents and low income group experienced a considerable rise and even outpaced its counterparts in urban areas and high income groups. On the one hand, these results were related to the social-economic development and the increase of residents’ income level. On the other hand, the significant increase of health care utilization after 2003 was largely attributed to the establishment of urban and rural health insurance schemes, the shrinking of differences in inpatient reimbursement rate, the increasing demand for health services, implying the achievement of China’s basic health insurance scheme. Lagged economic development in northeast regions impacted its increasing pace of health care utilization.

In summary, the 1993–2013 and 2013–2018 results show differential changes in outpatient care utilization. The inpatient care utilization has been rising for about three decades and the gaps in health care utilization between urban and rural areas, across regions and by income groups have been narrowed. It is important to note that although the accessibility of health services has been greatly improved in recent ten years, China’s health care system still faced great challenges by the increased trend in healthcare utilization mainly caused by increasing prevalence of chronic diseases [31‐33] and the prevention and management of diseases screening out more patients with chronic diseases and has large rooms to improve the accessibility and equity of health services.

China has experienced significant increases in health care utilization over the last 25 years. Annual Hospital admission rate increased year by year and the share of population with the unmet needs for health care decreased remarkably. Meanwhile, the gaps in health care utilization between urban and rural areas, across regions and by income groups have been narrowed, implying that equality has been improved. These results imply great achievements in better healthcare access in China. These achievements are closely related to the expansion of social health insurance schemes, better financing protection, the shrinking of the gap in inpatient reimbursement rate across regions and income groups, as well as improved chronic disease management due to China’s health care reform.