Journal Article

Does the hierarchical medical system enhance healthcare utilization and equity in China? a longitudinal study 2012–2018

Wang, Chunkai, Gao, Yuan, Fan, Xiaojing, Zhao, Xiaofeng, Li, Lili, Zhao, Yaxin, Zhu, Fukun

2025

Overview

Background 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. Methods 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. Results 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. Conclusion 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.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Adult / Attainment / Biostatistics / China / Chinese languages / Chronic illnesses / Decomposing analysis / Decomposition / Demographic aspects / Discrimination in medical care / Economic aspects / Economics / Education / Educational attainment / Educational inequality / Environmental Health / Epidemiology / Fairness / Family studies / Female / Health care / Health care access / Health care disparities / Health care industry / Health care policy / Health disparities / Health education / Health Equity / Health insurance / Health services / Health Services Accessibility / Health services utilization / Health status / Healthcare Disparities - statistics & numerical data / Heterogeneity / Hierarchical medical system / Hierarchies / Horizontal inequity / Humans / Improving social inequities in health in the Global South / Indexes / Inequality / Inequality in healthcare utilization / Infrastructure / Inpatient care / Insurance / Insurance coverage / Longitudinal Studies / Low income groups / Male / Medical care / Medicine / Medicine & Public Health / Middle Aged / Outpatient services / Patient Acceptance of Health Care - statistics & numerical data / Pharmacists / Policy making / Prevention / Primary care / Public Health / Resource allocation / Rural areas / Rural communities / Social aspects / Socioeconomic Factors / Sustainable development / Utilization / Vaccine