Rising Health Care Inequalities in Transition China: What Do We Really Know?

Presenter: Chung-Ping Loh

Abstract

In recent decades China has experienced dramatic transitions that have affected health care access. Both average incomes and income inequality have risen rapidly, and health care prices have risen as the government’s role in health care provision has diminished. Many have predicted that as a result socioeconomic inequalities in health care utilization must have increased over this time period, reversing China’s historical efforts to ensure equitable access to health care. A number of studies have empirically analyzed changing health care disparities, and many in the field have concluded that disparities have indeed increased. A careful review of the existing empirical literature, however, suggests that empirical evidence on this issue is actually quite weak. First, many of these studies cite aggregate statistics from the Chinese government’s National Health Service Surveys (NHSS), but those microdata have not been released for independent analysis, and studies have not reported tests of whether the reported changing trends are statistically significant. Second, these studies are typically based on changes between two relatively close time points, which may not accurately reflect long term underlying trends; indeed, there appears to be publication bias that has highlighted short term increases in inequalities but ignored instances of short-term decreases in inequalities.

This paper provides a more extensive examination of the health care utilization patterns in China from the early 1990s through 2004. Using two nationally representative datasets – National Health Service Surveys (1993, 1998, and 2003) and the longitudinal China Health and Nutrition Survey (1991, 1993, 1997, 2000, and 2004) – this study analyzes the utilization patterns of outpatient visits and hospitalization by socioeconomic indicators including education, income, wealth and rural-urban status.

The study has the following major findings: First, overall outpatient visit rates remain largely unchanged between 1993 and 2000 and rose after 2000. The highest income quartile in urban areas, however, has seen secular increases in outpatient care usage since 1993, leading to rising inequality in outpatient care usage in urban areas. Inpatient visits follow a declining trend in rural areas and for the lowest income quartile in the urban areas since 1993, while a fluctuating pattern is observed for the higher income groups in the urban area.

We also find that some of the short-term health care inequality changes documented in previous literature appear to be unstable, with numerous instances of short-term reversals between 1991 and 2004. The reversals appear more frequently in urban areas, which may reflect the dynamic changes in social and economic conditions in urban areas. This provides a cautionary warning about limitations of relying on short-term changes for drawing conclusions about broad secular changes occurring in a dynamic setting such as transition China.