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01.12.2012 | Research article | Ausgabe 1/2012 Open Access

BMC Health Services Research 1/2012

Growing old before growing rich: inequality in health service utilization among the mid-aged and elderly in Gansu and Zhejiang Provinces, China

BMC Health Services Research > Ausgabe 1/2012
Yang Wang, Jian Wang, Elizabeth Maitland, Yaohui Zhao, Stephen Nicholas, Mingshan Lu
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1472-6963-12-302) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

YW and JW conceptualized and supervised the study, contributed to the study design, made substantial contributions to the acquisition and quality assurance of the data, and analyzed the data. YZ takes a leading role in the acknowledge funding project in which makes it able to write the paper. EM and SN contributed to the study design, survey conduction and supervision, as well as interpretation and writing of the manuscript. ML contributed to the statistical analysis, interpretation, writing and finalizing of the manuscript. All authors read and approved the final manuscript.



China’s recent growth in income has been unequally distributed, resulting in an unusually rapid retreat from relative income equality, which has impacted negatively on health services access. There exists a significant gap between health care utilization in rural and urban areas and inequality in health care access due to differences in socioeconomic status is increasing. We investigate inequality in service utilization among the mid-aged and elderly, with a special attention of health insurance.


This paper measures the income-related inequality and horizontal inequity in inpatient and outpatient health care utilization among the mid-aged and elderly in two provinces of China. The data for this study come from the pilot survey of the China Health and Retirement Longitudinal Study in Gansu and Zhejiang. Concentration Index (CI) and its decomposition approach were deployed to reflect inequality degree and explore the source of these inequalities.


There is a pro-rich inequality in the probability of receiving health service utilization in Gansu (CI outpatient = 0.067; CI inpatient = 0.011) and outpatient for Zhejiang (CI = 0.016), but a pro-poor inequality in inpatient utilization in Zhejiang (CI = −0.090). All the Horizontal Inequity Indices (HI) are positive. Income was the dominant factor in health care utilization for out-patient in Gansu (40.3 percent) and Zhejiang (55.5 percent). The non-need factors’ contribution to inequity in Gansu and Zhejiang outpatient care had the same pattern across the two provinces, with the factors evenly split between pro-rich and pro-poor biases. The insurance schemes were strongly pro-rich, except New Cooperative Medical Scheme (NCMS) in Zhejiang.


For the middle-aged and elderly, there is a strong pro-rich inequality of health care utilization in both provinces. Income was the most important factor in outpatient care in both provinces, but access to inpatient care was driven by a mix of income, need and non-need factors that significantly differed across and within the two provinces. These differences were the result of different levels of health care provision, different out-of-pocket expenses for health care and different access to and coverage of health insurance for rural and urban families. To address health care utilization inequality, China will need to reduce the unequal distribution of income and expand the coverage of its health insurance schemes.
Authors’ original file for figure 1
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