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Original research
Ten years of progress towards universal health coverage: has China achieved equitable healthcare financing?
  1. Mingsheng Chen1,2,3,
  2. Guoliang Zhou1,
  3. Lei Si4,5
  1. 1School of Health Policy and Management, Nanjing Medical University, Nanjing, China
  2. 2Creative Health Policy Research Group, Nanjing, China
  3. 3Center for Global Health, Nanjing Medical University, Nanjing, China
  4. 4The George Institute for Global Health, UNSW Sydney, Kensington, New South Wales, Australia
  5. 5UNSW Medicine, UNSW Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Lei Si; lsi{at}georgeinstitute.org.au

Abstract

Introduction This study aims to systematically evaluate vertical and horizontal equity in the Chinese healthcare financing system over the period 2008–2018 during the progress towards Universal Health Coverage (UHC), and to examine how both types of equity have changed during this period.

Methods Household information on healthcare payments was collected from 2398 households involving 7021 individuals in 2008, 3600 households involving 10 466 individuals in 2013 and 3660 households involving 11 550 individuals in 2018. Redistributive effects of healthcare financing system were decomposed into progressivity, pure horizontal inequity and reranking. Progressivity analysis and the Aronson-Johnson-Lambert decomposition method were adopted to measure the vertical equity and horizontal equity of healthcare financing.

Results Over the period 2008–2018, healthcare financing through indirect taxes showed a slightly prorich structure and healthcare financing through direct taxes showed a propoor structure in both urban and rural areas. Urban Employee Basic Medical Insurance experienced redistribution from the poor to the rich during the period 2008–2013, but then experienced redistribution from the rich to the poor during the period 2013–2018. Urban Resident Basic Medical Insurance (URBMI), New Rural Cooperative Medical Scheme (NRCMS), Urban and Rural Resident Basic Medical Insurance (URRBMI) and out-of-pocket payments experienced redistribution from the poor to the rich over the entire period.

Conclusion China’s healthcare financing has experienced redistribution from the poor to the rich during 10 years of progress toward the UHC. UHC improved access to and utilisation of healthcare in urban areas. The flat rate contribution mechanism should be renovated for URBMI, NRCMS and URRBMI.

  • health insurance
  • health policy
  • health services research
  • health systems
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgh-2020-003570

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    Footnotes

    • Handling editor Sanni Yaya

    • Contributors LS led and designed the study. GZ led the data collection, analysis and interpretation. MC contributed to the study design and data analysis, and wrote the first draft of the manuscript. LS contributed to the data analysis, reviewed the manuscript and helped write the final draft manuscript. All authors reviewed the content of the final version of the manuscript.

    • Funding This study is funded by the National Natural Science Foundation of China (grant number: 71503137, 71874086) and the China Medical Board (grant number: 19-346). LS is supported by an NHMRC Early Career Fellowship (grant number: GNT1139826).

    • Disclaimer The funding bodies were not involved in the design of the study, or data collection, analysis, and interpretation or in writing the manuscript.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available on request. The authors will make data available to scientists planning specified and agreed further analyses; for access, contact the corresponding author.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.