Zhao Yaxin, Fan Xiaojing, Zhu Fukun, Li Lili, Zhao Xiaofeng, Wang Chunkai, Gao Yuan
College of Humanities & Social Development, Northwest A&F University, No.22 Xinong Road, Xianyang, Shaanxi, 712100, China.
School of Public Policy and Administration, Xi'an Jiaotong University, No.28 Xianning West Road, Xi'an, Shaanxi, 710049, China.
BMC Public Health. 2025 Aug 11;25(1):2731. doi: 10.1186/s12889-025-23933-4.
Healthcare inequities pose a substantial challenge to achieving universal health coverage, particularly in low- and middle-income countries (LMICs). The Chinese government implemented Hierarchical Medical System (HMS) to optimize resource allocation and improve healthcare access. This study aimed to evaluate the impact of HMS on healthcare utilization and the inequities.
This study utilized longitudinal data from the China Family Panel Studies (CFPS) conducted in 2012, 2014, 2016, and 2018, which included a final sample of 105,335 individuals. A multiple-period difference-in-differences method was employed to explore the impact on outpatient and inpatient utilization across socioeconomic dimensions. The concentration Index and the horizontal inequity index (HI) were used to assess inequities in healthcare utilization. Additionally, a decomposition analysis was performed to identify the contributors to inequalities.
HMS demonstrated significant negative impacts on both outpatient and inpatient utilization (OR = 0.825, SE = 0.058; OR = 0.869, SE = 0.071, respectively), with a short-term decline in outpatient services and a lasting reduction in inpatient services. The heterogeneity tests revealed a pronounced impact in central and rural areas. The results indicated pro-poor inequities in outpatient utilization and pro-rich inequities in inpatient utilization. HMS reduced inequalities and inequities in healthcare utilization, particularly for outpatient services. HI in inpatient services increased in the initial year but decreased after 2 years of HMS. The decomposition analyses identified the primary contributors as economic level and health status. While the economic level exacerbated inequalities, health insurance and higher educational attainment mitigated inequalities in healthcare utilization.
HMS had an unintended impact on decreasing healthcare utilization in China. HMS improved equity in outpatient utilization, it faced challenges in enhancing equity in inpatient utilization. Policymakers should prioritize strengthening primary care infrastructure in central and rural areas, ensuring affordable healthcare models, reinforcing educational attainment, and expanding health insurance coverage to promote equity in healthcare utilization. These findings provide crucial insights for guiding equitable healthcare reform in LMICs and advancing progress toward the Sustainable Development Goals.
医疗保健不平等对实现全民健康覆盖构成重大挑战，在低收入和中等收入国家（LMICs）尤其如此。中国政府实施了分级医疗制度（HMS），以优化资源配置并改善医疗服务可及性。本研究旨在评估分级医疗制度对医疗服务利用及不平等现象的影响。
本研究使用了2012年、2014年、2016年和2018年中国家庭追踪调查（CFPS）的纵向数据，最终样本包括105335名个体。采用多期差分法探讨其对社会经济各维度门诊和住院服务利用的影响。使用集中指数和横向不平等指数（HI）评估医疗服务利用中的不平等现象。此外，进行了分解分析以确定不平等现象的影响因素。
分级医疗制度对门诊和住院服务利用均显示出显著的负面影响（OR分别为0.825，SE为0.058；OR为0.869，SE为0.071），门诊服务短期下降，住院服务持续减少。异质性检验显示在中部和农村地区影响显著。结果表明门诊利用存在有利于穷人的不平等，住院利用存在有利于富人的不平等。分级医疗制度减少了医疗服务利用中的不平等和不公平现象，尤其是门诊服务。住院服务的HI在第一年有所增加，但在分级医疗制度实施两年后下降。分解分析确定主要影响因素为经济水平和健康状况。虽然经济水平加剧了不平等，但医疗保险和较高的教育程度减轻了医疗服务利用中的不平等。
分级医疗制度在中国对减少医疗服务利用产生了意外影响。分级医疗制度改善了门诊利用的公平性，但在提高住院利用公平性方面面临挑战。政策制定者应优先加强中部和农村地区的基层医疗基础设施，确保可负担的医疗模式，提高教育程度，并扩大医疗保险覆盖范围，以促进医疗服务利用的公平性。这些发现为指导低收入和中等收入国家的公平医疗改革以及推动实现可持续发展目标的进展提供了重要见解。
