Inequality in the distribution of health resources and health services in China: hospitals versus primary care institutions

Despite great progress in health system reform, inequity in medical resources and medical care services remains a serious concern of many researchers and policymakers in China. Empirical evidence suggests that large inequity in resources and services can exacerbate disparities in health outcomes and quality of life [1, 2]. In recent years, the Chinese government has endorsed equity as an important indicator for health system evaluation [3, 4]. With almost universal coverage of social health insurance, health care accessibility and affordability of the poor and disadvantaged populations emerged to be top of the governmental agenda for further policy development [5].

In China, hospitals and primary care institutions deliver the majority of medical care services although, public health agencies and other institutions also play a role [6]. Hospitals are able to attract more and quality resources (such as a health workforce and health technologies) than their primary care counterparts. However, due to the large amount of primary care institutions and better accessibility, primary care can play a more crucial role in promoting regional health equity [7]. In comparison with hospitals, unfortunately, a serious shortage of resources exists in primary care institutions in China, leading to distrust from consumers. Services delivered by primary care institutions are deemed poor quality. They are unable to fulfill a gatekeeping function in the health system. It is common for consumers to seek medical attention from hospitals for minor illness or chronic conditions. Driven by the market forces, more resources have been poured into hospitals, further exacerbating disparities between hospitals and primary care institutions [8‐10].

Recently, inequity in medical resources and medical care services started to attract attention from researchers: some focused on certain medical conditions [11‐13]; others explored inequity in resources and services within the primary care sector [14, 15]. Hung argued that a big gap in resources and services between hospitals and primary care institutions exists and it continues to be increase despite the government’s favorable investment policies for the primary care sector [16]. But there is paucity in the literature documenting inequity in resources and services between hospitals and primary care institutions.

This study aimed to evaluate equity in medical resources and medical care services between hospitals and primary care institutions in China.

This study compared the hospital and primary care sector in China in terms of the distributions of health resources and health services. We found that most health workers and beds were allocated to hospitals despite there being a much larger number of primary care institutions (in China, primary care institutions comprise more than 96% of all health institutions [6]). Meanwhile, hospitals developed more rapidly than primary care institutions. This may impose a risk of further enlarging the capacity gap between hospitals and primary care institutions, jeopardizing the governmental effort to strengthen primary care. The most recent round of health reform launched in 2009 has a strong focus on primary care. Although some progress has been made with increased governmental investments in primary care, the capacity development of primary care still lags behind the hospital sector. Several other studies in China also found that quality resources tend to be increasingly concentrated in hospitals [13, 25]. Low wages and lack of career opportunities have often been blamed for the shortage of primary care workers and the loss of quality health workers to hospitals [6].

Inequality in health resources is mainly reflected in geographic distributions (density) instead of per capita (population) distribution. The Gini coefficients exceeded 0.7 in the geographic distribution of resources, much higher than those of per capita population distribution of resources. This is not surprising given that most resource planning programs have considered population size [26]. But few have been concerned about the geographic density of resources. Conversely, health services operated in scarcely populated, large geographic catchments are often poorly resourced because they are more expensive to operate [27]. However, residents living in less populated areas, such as rural districts, are often disadvantaged in China with lower income and less support. Those people deserve more policy attention.

We found significant regional disparities in the distribution, in particular the geographic distribution of health resources. The eastern developed region has a higher level of resources than the other two regions. This finding is consistent with other studies [27]. The larger size and the higher density of populations in the eastern region mean that its operational costs of health services are relatively cheaper. Meanwhile, the decentralized governmental budgeting process means that the wealthy eastern provinces have a higher financial capacity to fund health services. The health services in the eastern region can also offer a better salary and welfare to health workers, enticing quality health workers from the less developed regions to move to the east. Indeed, previous studies show that.most quality health resources are concentrated in hospitals, especially in tertiary hospitals, of which 46.68% are located in the eastern provinces in China. It was estimated that 30% of provinces in China have attracted 50% of quality health resources [6].

The outpatient visits to primary care institutions outnumbered those to hospitals, not only because the number of primary care institutions is large, but also because they are geographically close to residents, easy to access, and cheap. Understandably, most people chose hospitals for inpatient care. What is concerning is that the volume of inpatient care grew much faster than outpatient care over the years from 2010 to 2014, in particular for those provided by the hospital sector. This is aligned with the stronger growth of hospital resources. At the same time, the growth of outpatient care services was marginal, indicating a relatively weaker primary care sector.

Regional disparities exist in health services utilization. Residents living in the eastern developed zone were more likely to use hospitals for outpatient care than their poorer central and western counterparts. On the other hand, residents living in the western undeveloped zone were more likely to use primary care institutions for inpatient care than their eastern and central counterparts. This is clearly associated with the gap in income level and health expenditure [28‐30]. The CI indicates that outpatient care provided by hospitals tends to concentrate on the richer; whereas, inpatient care provided by primary care institutions tends to concentrate on the poorer. Such a two-tier system is worrisome. Empirical evidence shows that both the overuse of services (such as hospital care) and the under use of services (such as primary care) coexist in China [31].

The internal disparities within each economic zone further illustrate the regional differences in the equality of health care. The eastern developed region has a much higher level of inequality compared with the other regions. Similar results were also found in previous studies [32]. The inequality in outpatient care and hospital inpatient care, as indicated by the CI values, was actually growing in the eastern region, enlarging the regional gaps in CI. In addition, the regional CI gap in inpatient care provided by primary care institutions, the only service that tends to concentrate on the poor, shrank over the years. The less developed regions have to learn how to mitigate the risk of growing inequality in their development process.

This study has several policy implications. Firstly, more health resources, especially quality health worker, should be allocated to primary care institutions in order to narrow the capacity gap between hospitals and primary care institutions. Secondly, regional disparities need to be addressed. This can only be done through financial transfer coordinated by the central government. The current governmental budgeting system and the social health insurance arrangements in China are highly decentralized and fragmented, preventing the central government from fulfilling this role. Thirdly, more attention needs to be paid to the potential emergence of a two-tier system, where the well-resourced facilities (such as hospitals) favor the rich and the poorly resourced facilities (such as primary care institutions) favor the poor. Finally, a tiered health care delivery system needs to be developed, in which the function of primary care institutions complements that of hospitals. Consumers should be able to access different services based on their health care needs, not their ability to pay.

Significant inequality in the geographic distribution of health resources is evident, despite a more equitable per capita distribution of resources. The residents living in the eastern developed region are more likely to use the well-resourced hospitals for outpatient care. By contrast, the residents living in the western undeveloped region are more likely to use the poorly-resourced primary care institutions for inpatient care. Apart from regional disparities, inequality within each region also exists. The wealth-related inequality in the eastern developed region is increasing, further enlarging the regional gaps in CI.