Rural and urban differences in health system performance among older Chinese adults: cross-sectional analysis of a national sample

Vicky Mengqi Qin,Thomas E Cowling,John Tayu Lee,Rifat Atun,Kee Seng Chia,Barbara Mcpake,Riyadh Alshamsan,Magdalena Z Raban,Peter C Smith

doi:10.1186/s12913-020-05194-6

Abstract

BackgroundDespite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities. There is limited research on the rural-urban differences in health system performance in China.MethodWe conducted a cross-sectional analysis to compare health system performance between rural and urban areas in five key domains of the health system: effectiveness, cost, access, patient-centredness and equity, using data from the WHO Study on Global AGEing and adult health (SAGE), China. Multiple logistic and linear regression models were used to assess the first four domains, adjusting for individual characteristics, and a relative index of inequality (RII) was used to measure the equity domain.FindingsCompared to urban areas, rural areas had poorer performance in the management and control of hypertension and diabetes, with more than 50% lower odds of having breast (AOR = 0.44; 95% CI: 0.30, 0.64) and cervical cancer screening (AOR = 0.49; 95% CI: 0.29, 0.83). There was better performance in rural areas in the patient-centredness domain, with more than twice higher odds of getting prompt attention, respect, clarity of the communication with health provider and involvement in decision making of the treatment in inpatient care (AOR = 2.56, 2.15, 2.28, 2.28). Although rural residents incurred relatively less out-of-pocket expenditures (OOPE) for outpatient and inpatient services than urban residents, they were more likely to incur catastrophic expenditures on health (AOR = 1.30; 95% CI 1.16, 1.44). Wealth inequality was found in many indicators related to the effectiveness, costs and access domains in both rural and urban areas. Rural areas had greater inequalities in the management of hypertension and coverage of cervical cancer (RII = 7.45 vs 1.64).ConclusionOur findings suggest that urban areas have achieved better prevention and management of non-communicable disease than rural areas, but access to healthcare was equivalent. A better understanding of the causes of the observed variations is needed to develop appropriate policy interventions which address these disparities.

Highlights

Despite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities
Our findings suggest that urban areas have achieved better prevention and management of noncommunicable disease than rural areas, but access to healthcare was equivalent
Effectiveness domain Overall, respondents living in rural areas fared adversely in most indicators in the effectiveness domain compared to respondents in urban areas (Table 1)

Summary

Introduction

Despite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities. Since the economic liberalization which began in the 1980s, China has experienced rapid economic growth (more than a 30-fold increase in gross national income per capita from US$220 in 1980 to US$8690 in 2017, at current US$) and improvements in health outcomes (average life expectancy at birth increased by more than 8 years in 2015) [1, 2] These national averages obscure gross rural-urban inequities in outcomes [3, 4]. To ensure equitable access to health services, since 2014, social health insurance reforms have been focusing on transforming from dual to integrated health insurance system [15] This includes long-term efforts at vertical consolidation (rural NCMS and urban URBMI and UEBMI) and horizontal consolidation (fund pools and benefit packages) [15, 16]

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