Urban-rural disparities in health care utilization among Chinese adults from 1993 to 2011

Ensuring equitable access to health services is an enduring concern for health system planners and policy-makers [1]. Despite economic growth and improved health outcomes over the past few decades in China, previous studies indicate significant urban-rural inequality in health related issues such as health care resources [2, 3], health outcomes in adults and children [3‐6], and prevalence of certain diseases [7‐12]. Compared with urban residents, infant mortality in the rural population was over 2 times higher (5.2 of 1000 vs. 12.4 of 1000) and health expenditures per capita were nearly one third lower (2969 yuan vs. 1056 yuan) in 2012 [13]. Although many factors account for the large gap between urban and rural environments, access to the health care system is a pivotal factor [14]. Equitable utilisation of health care is now a research priority in China [1].

A number of studies have compared the differences between rural and urban residents in the utilization of medical care services. Research has generally found lower utilization of all sorts of health care services in the rural area [1, 15‐22], due to the unbalanced development between urban and rural areas in medical service supply. Urban–rural health disparities are expected to be even more pronounced in China since the Chinese government enforces a household registration system (hukou) to control internal migration. The hukou system, established in 1955, classified all residents into agricultural (rural) and non-agricultural (urban) registration categories. During the era of planned economy (1956~ 1978), the policy favoured urban hukou holders in many ways such as employment opportunities, ration stamps, housing, and subsidized services. Following China’s economic transition and urbanization in the 1980s, a large number of rural residents moved to cities without converting their hukou status. During period of this study (1993~ 2011), although the government gradually eased the hukou regulations, rural residents still encountered barriers in obtaining basic public services and welfare such as healthcare, education system, and social security coverage [23, 24]. For example, the social health insurance system has been separated into the urban system and rural system by hukou. Urban employees and unemployed residents respectively obtain health insurance through programs called Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI), whereas rural hukou holders are stipulated to participate in a community health insurance scheme known as the New Cooperative Medical System (NCMS) [25, 26]. Compared with the urban insurance, rural health insurance has inferior health coverage and inconvenient reimbursement procedures, which result in potential barriers for rural residents to obtain appropriate and cost-effective health care [27, 28]. Therefore, we estimate urban-rural disparities from the perspective of hukou in this study.

Health care utilization is the most activity-related and consumer-oriented problem in planning health care delivery [21]. The Chinese government conducted an array of reforms aimed at narrowing urban-rural disparities since 1997 [9]. Previous studies, which have been based on a cross-sectional or early period database [29‐32], may not reflect the longitudinal effects of the reform activities. Given this background, our study seeks to meet three objectives: first, to explore the extent to which rural and urban patients differed in health care utilizing behaviour in view of hukou; second, to determine how much of the variation in health care utilization remains once other determinants are accounted for; and third, to examine trends of urban-rural disparities in health care utilization by capitalizing on a longitudinal database from 1993 to 2011.

The present study showed that more than half of patients chose outpatient care as their treatment option when they felt sick during the 4 weeks before the survey. However, although an insignificant increase in outpatient care utilization could be observed from 2004 to 2011 when holding everything else constant, the probability of choosing outpatient care was much lower than that before 2000. Instead, patients were more likely to use self-care since 2000. The most straightforward explanation for this phenomenon would be the sharp rise in health service costs. Between 1995 and 2011, average per capita health expenditures increased from 110.1 to 969.0 yuan among urban residents, and from 42.5 to 436.8 yuan among rural residents [13]. Some urban and many rural residents who could not afford such medical expenditures had to buy drugs from pharmacies [40], even for serious diseases like HIV/AIDS [41]. Additionally, the Chinese government has implemented the drug sales network in recent years, which highly improved the accessibility of pharmacies and medicines [40]. Some studies found that the aging population might be responsible for the increasing self-care utilization because seniors relied more on self-care to save the economic and time cost involved in seeking professional health care [42]. In developing countries, where heath service resources are scarce, despite being associated with risks [43], self-care should be an important supplemental approach to professional medical facilities. As the role of pharmacies in health care has been recognized by many countries [43‐45], those pharmacies in China should take more responsibility for self-care monitoring and management.

We also concluded that rural hukou holders used less health care than their urban counterparts. Moreover, the hukou distinction in inpatient care utilization was more obvious than the distinctions in self-care and inpatient care utilization. These findings were consistent with earlier studies about urban-rural gaps in health care utilization [9, 29, 46, 47]. More specifically, rural residents had a higher proportion of outpatient care than urban residents in the descriptive results but had a lower probability of using outpatient care in the multivariate results after controlling for the confounding variables. The opposite results demonstrated that the urban-rural disparities on health care utilization were even more obvious than observed.

There are several potential explanations for the urban-rural disparities observed in this study. First, consistent with most previous studies from other countries, people in rural areas usually have a shortage of health care providers, extended travel, low socioeconomic status, and lack social support [1, 3, 48‐51] [16]. Registered doctors per thousand populations in urban communities were 2.57 times more than in rural communities in China [13]. The second explanation is the different welfare system between urban and rural, due hukou. The major welfare benefit associated hukou is the social benefits system including health insurance [23, 52, 53]. The rural hukou holders are stipulated to participate in the local NCMS, which has lower benefit than that of the UEBMI and URBMI in urban areas. In 2008, the actual co-payment rates of UEBMI, URBMI, and NCMS were 36.8%, 50.7%, and 73.4%, respectively [54]. Under the two-class health insurance system, rural residents usually encounter more financial barriers in health care utilization. The average hospitalization expenses of the NCMS enrolees account for 56% of per capita annual income in 2008, while the proportions for UEBMI and URBMI enrolees are only 31.8% and 38.2%, respectively [54]. Such heavy burden compels rural patients to stay away from inpatient care, which can also explain why we could observe a larger urban-rural gap in inpatient care use than self-care and outpatient care use. Our findings suggested that extending health insurance coverage may have limited effect on promoting urban-rural equity, and integrating the decentralized insurance system into one uniform system should be taken into consideration. Moreover, the lack of inpatient health services provision in rural areas and the consequent long distance to gain access to appropriate treatment may also function as significant obstacles for rural residents to access and use inpatient health care.

An encouraging finding was that the urban-rural disparities in health care utilization had narrowed from 1993 to 2011, though not significantly before 2009. The continuous coverage expansion and benefit improvement of rural health insurance might have played a positive role in the gap narrowing. Between 1993 to 2013, the rural insurance coverage extended from 15.9% to 97.3% [54]. Besides, The central and local government subsidy increased from minimum 20 yuan in 2003 to 80 yuan in 2008, and to minimum 120 yuan in 2010 per enrolee per year [54]. Recently, immediate reimbursement from NCMS has been realized in more and more rural areas, which means NCMS enrolees only need to pay out-of-pocket for part of their medical expenditure [55]. All these reasons might work together to lower the financial barrier and to promote equal use of health care. More specifically, obvious decrements could be observed in self-care, outpatient care, and inpatient care since 2009, which might be due to the new nationwide health care system reform in China. In 2009, the central government of China started new health care reforms, which targeted universal and equitable access to health care by 2020 [46, 56]. Between 2009 and 2011, 850 billion yuan had been spent in expanding health insurance coverage, improving primary care, establishing essential medicines system, promoting public health services, and piloting public hospital reform [56, 57]. All the initiatives mentioned above might have contributed to the decrements. Moreover, the decline in inpatient care utilization was more obvious than the changes in self-care and outpatient care use, which could be associated with the NCMS reimbursement policies that focus on inpatient coverage [46]. Considering that primary care is more affordable and efficient in reducing health disparities [58], greater attention should be given to covering the costs of primary care through NCMS, such as the coverage of chronic disease management and treatment.

Our findings on trends in urban-rural disparities were consistent with Meng et al. [46]. However, earlier research conducted by Liu et al. and Gao et al. showed widening gaps in health care utilization between urban and rural from 1980s to 1993 and from 1993 to 1998, respectively [47] [59], which was opposite to our multivariate findings. There are several possible explanations for the discrepancy between their studies and our findings. First, Liu et al. and Gao et al. used secondary data sources without adjusting for confounders. Our results on trends of the raw urban-rural gaps had similar differences from the trends after controlling confounding variables. Second, Liu et al. and Gao et al. used living location to distinguish between urban and rural, while we defined urban and rural residents by hukou. During the past few decades, large-scale young people moved into cities leaving the elderly behind in the countryside, which might result in a more rapidly aging trend in rural areas compared to urban areas [12]. Most of these rural-to-urban migrants still held rural hukou and would not affect our results.

In addition, our findings suggested that the pattern of health seeking behaviours were different among different areas. For example, patients in central and eastern regions were less likely to use self-care and were more likely to use outpatient care, while patients in the north-eastern region were more intent on using self-care and were less likely to use professional health service. This reflected the uneven distribution of health resources among different parts of China [58]. Correspondingly, different policy interventions should be implemented to improve health care utilization accordingly. The government should improve the health infrastructure in undeveloped regions to encourage people to use health services when needed. For the eastern region, improving the primary care to disperse crowds of patients at big hospitals need further efforts.

Despite these limitations, this study is among the first to investigate the urban-rural disparities in health care seeking behaviours associated with hukou. Also, we used a longitudinal individual-level database including the most recent data, which explored some up-to-date findings on trends in urban-rural disparities. The present study showed that rural residents were still underutilizing health care when compared to their urban counterparts, and institutional differences between urban and rural in health care utilization were more notable than observed from statistical data. Fortunately, the Chinese government abolished the urban and rural hukou distinction in October 2014. Our findings attest to the wisdom of this abolishment. Although the urban-rural disparities have declined between 1993 and 2011, policy makers still need to be aware of the challenges due to aging problems and health expenditure increases. Therefore, a comprehensive approach to achieving and maintaining equity in health and heath care utilization may focus on: integrating the decentralized insurance system into one uniform system, providing more primary care services covered by health insurance, and equitable and reasonable allocation of health resources between urban and rural areas.