Elsevier

The Lancet

Volume 379, Issue 9818, 3–9 March 2012, Pages 805-814
The Lancet

Articles
Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study

https://doi.org/10.1016/S0140-6736(12)60278-5Get rights and content

Summary

Background

In the past decade, the Government of China initiated health-care reforms to achieve universal access to health care by 2020. We assessed trends in health-care access and financial protection between 2003, and 2011, nationwide.

Methods

We used data from the 2003, 2008, and 2011 National Health Services Survey (NHSS), which used multistage stratified cluster sampling to select 94 of 2859 counties from China's 31 provinces and municipalities. The 2011 survey was done with a subset of the NHSS sampling frame to monitor key indicators after the national health-care reforms were announced in 2009. Three sets of indicators were chosen to measure trends in access to coverage, health-care activities, and financial protection. Data were disaggregated by urban or rural residence and by three geographical regions: east, central, and west, and by household income. We examined change in equity across and within regions.

Findings

The number of households interviewed was 57 023 in 2003, 56 456 in 2008, and 18 822 in 2011. Response rates were 98·3%, 95·0%, and 95·5%, respectively. The number of individuals interviewed was 193 689 in 2003, 177 501 in 2008, and 59 835 in 2011. Between 2003 and 2011, insurance coverage increased from 29·7% (57 526 of 193 689) to 95·7% (57 262 of 59 835, p<0·0001). The average share of inpatient costs reimbursed from insurance increased from 14·4 (13·7–15·1) in 2003 to 46·9 (44·7–49·1) in 2011 (p<0·0001). Hospital delivery rates averaged 95·8% (1219 of 1272) in 2011. Hospital admissions increased 2·5 times to 8·8% (5288 of 59 835, p<0·0001) in 2011 from 3·6% (6981 of 193 689) in 2003. 12·9% of households (2425 of 18 800) had catastrophic health expenses in 2011. Caesarean section rates increased from 19·2% (736 of 3835) to 36·3% (443 of 1221, p<0·0001) between 2003 and 2011.

Interpretation

Remarkable increases in insurance coverage and inpatient reimbursement were accompanied by increased use and coverage of health care. Important advances have been made in achieving equal access to services and insurance coverage across and within regions. However, these increases have not been accompanied by reductions in catastrophic health expenses. With the achievement of basic health-services coverage, future challenges include stronger risk protection, and greater efficiency and quality of care.

Funding

None.

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.

Section snippets

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

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