ArticlesTrends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study
Introduction
The changes in China's health system in the past few decades have been remarkable. After 1978, the government's economic liberalisation policies led to rapid economic growth and poverty reduction. However, the performance of the health system did not improve at the same pace as did the economy.1, 2, 3 Local governments were given the responsibility for health care, and user fees were implemented as public funding decreased. Sales of medicines and services became the main source of operational funds for public health facilities. By 2001, 60% of total health expenditures were out-of-pocket.4 Access to health care became more difficult for those who could not pay. Because of the need to attract private individual spending, the health-service sector expanded in urban areas. Growing inequalities between rural and urban areas in health-care use and health outcomes were reported.5, 6 In response, insurance reforms were initiated between 2003 and 2008 to achieve better access and risk protection. The appendix describes the evolution of the major health-insurance programmes,7, 8, 9 and the changes in coverage.
A comprehensive reform of the health-care system was however recognised to be needed. Pilots were undertaken to study how essential health services could be financed and delivered.10 After careful consideration, the State Council announced in 2009 a systematic plan to achieve universal coverage by 2020.11 Between 2009 and 2011, the reforms focused on five areas: service delivery, essential medicines, public health, insurance, and public hospital reform (appendix).12 By mid-2011, the government announced its intention to increase investments in the 3-year plan to 1·13 trillion CN¥ (US$173·8 billion, 6·5 ¥ per $).13
Crucial questions remain about the response to major reforms and the large influx of additional resources. Monitoring systems have been put into place to see how the reforms are progressing. This study provides up-to-date evidence of trends in access to health services and financial protection between 2003 and 2011, and of whether inequalities across regions and income groups have decreased with time.
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Study design and data sources
All three rounds (2003, 2008, and 2011) of the National Health Services Survey (NHSS) used in this study were done with a multistage cluster sampling method, stratified by province, in which 94 counties in China's 31 provinces, autonomous regions, and municipalities were selected from 2859 counties. The NHSS has been done at 5-year intervals since 1993; the 2003 survey was done in September and October, and the 2008 and 2011 surveys were both done in June and July. The 2011 survey was done with
Results
Table 1 presents the number of households interviewed, the response rates, the basic characteristics of the respondents in 2003, 2008, and 2011, which are well balanced for most variables. Household incomes grew annually by 9·2% in urban and 13·1% in rural areas between 2003 and 2011.
Physical access to health services slightly increased between 2008 and 2011, with gains in rural areas, and western and central regions (table 2). Use of outpatient care was fairly similar across China and
Discussion
Data from three nationally representative surveys indicate positive trends in access to and use of health services since 2003. The strongest increases could be seen in hospital admissions, hospital delivery, and antenatal care, and for insurance coverage and inpatient reimbursement rates. An impressive achievement is the expansion of health-insurance coverage to 95·7%, covering about 1·28 billion people. Physical access to health services was achieved for 83·3% of the population.
These trends
References (19)
- et al.
China's health system performance
Lancet
(2008) Medical insurance system evolution in China
China Econ Rev
(2009)- et al.
Dramatic increase of cesarean deliveries in the midst of health reforms in rural China
Soc Sci Med
(2010) - et al.
Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America
Lancet
(2006) - et al.
From a national, centrally planned health system to a system based on the market: lessons from China
Health Aff (Millwood)
(2008) - et al.
The Chinese health system at a crossroads
Health Aff (Millwood)
(2008) - et al.
China's health system and its reform: a review of recent studies
Health Econ
(2009) Center for Health Statistics and Information, Reports of Nation Health Service Survey Summary
(2004)
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