Toward Universal Health Coverage: Regional Inequalities and Potential Solutions for Alleviating Catastrophic Health Expenditure in the Post-poverty Elimination Era of China

Document Type : Original Article


1 Department of Global Health, School of Public Health, Peking University, Beijing, China

2 School of Public Health, Peking University, Beijing, China

3 China Center for Health Development Studies, Peking University, Beijing, China


This study took Beijing as an example to estimate the incidence and regional inequalities of catastrophic health expenditures (CHEs) in a megacity of China.

This study used data from the Health Services Survey Beijing (HSSB) 2018. Logistic regressions were used to investigate the risk factors for experiencing CHE, and concentration curves, the concentration index and its decomposition method based on probit models were used to estimate the inequalities in CHE.

CHE occurred in 25.51% of the households of the outer suburb villages, 6.78% of the households of the innercity area communities, 17.10% of the households of the villages of the inner-city areas, and 11.91% of the households of the communities of the outer suburbs. In areas in the outer suburbs, households with private insurance coverage were associated with a lowered risk of CHE, and lower educational attainment and lower occupational class were related to an increasing risk of CHE. This study also discovered pro-rich financing disparities in CHE in Beijing, with the outer suburbs having the highest levels of CHE disparity. When it comes to the observed contributions of disparities in CHE, a significant portion of them is connected to the sorts of occupations, educational levels, and residential status.

The impoverishment brought on by medical expenses and CHE must still be taken into account in the postpoverty elimination era. The megacity of China was discovered to have significant regional differences in the incidence of pro-rich financing inequity in CHE. Disparities in socioeconomic status (SES), one of the controllable variables, may be a key area to address to lower the risk and minimize CHE inequality in megacities towards the path to universal health coverage (UHC). Additionally, it is important to consider the financial protection impact of inclusive supplementary medical insurance on lowering the likelihood of CHE in the periphery areas.


  1. Evans DB, Etienne C. Health systems financing and the path to universal coverage. Bull World Health Organ. 2010;88(6):402. doi:2471/blt.10.078741
  2. Li Y, Wu Q, Xu L, et al. Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance. Bull World Health Organ. 2012;90(9):664-671. doi:2471/blt.12.102178
  3. Yip W, Fu H, Chen AT, et al. 10 years of health-care reform in China: progress and gaps in universal health coverage. Lancet. 2019;394(10204):1192-1204. doi:1016/s0140-6736(19)32136-1
  4. Hsu J, Majdzadeh R, Mills A, Hanson K. A dominance approach to analyze the incidence of catastrophic health expenditures in Iran. Soc Sci Med. 2021;285:114022. doi:1016/j.socscimed.2021.114022
  5. Huang D, Liu Z, Zhao X, Zhao P. Emerging polycentric megacity in China: an examination of employment subcenters and their influence on population distribution in Beijing. Cities. 2017;69:36-45. doi:1016/j.cities.2017.05.013
  6. Beijing Municipal Health Commission. Beijing Medical and health facilities special planning. 2020-2035.
  7. Lu C, Zhang Z, Lan X. Impact of China's referral reform on the equity and spatial accessibility of healthcare resources: a case study of Beijing. Soc Sci Med. 2019;235:112386. doi:1016/j.socscimed.2019.112386
  8. Zhong S, Yang X, Chen R. The accessibility measurement of hierarchy public service facilities based on multi-mode network dataset and the two-step 2SFCA: a case study of Beijing’s medical facilities. Geogr Res. 2016;35(4):731-744. doi:11821/dlyj201604011
  9. Huang F, Gan L. The impacts of China's urban employee basic medical insurance on healthcare expenditures and health outcomes. Health Econ. 2017;26(2):149-163. doi:1002/hec.3281
  10. Chen J, Lin Z, Li LA, et al. Ten years of China's new healthcare reform: a longitudinal study on changes in health resources. BMC Public Health. 2021;21(1):2272. doi:1186/s12889-021-12248-9
  11. Li L, Fu H. China's health care system reform: progress and prospects. Int J Health Plann Manage. 2017;32(3):240-253. doi:1002/hpm.2424
  12. Jiang Y, Ni W. Impact of supplementary private health insurance on hospitalization and physical examination in China. China Econ Rev. 2020;63:101514. doi:1016/j.chieco.2020.101514
  13. Zhu K, Zhang L, Yuan S, Zhang X, Zhang Z. Health financing and integration of urban and rural residents' basic medical insurance systems in China. Int J Equity Health. 2017;16(1):194. doi:1186/s12939-017-0690-z
  14. Center for Health Statistics and Information of Beijing Municipal Health Commission. An Analysis Report of Health Services Survey Beijing, in China, 2018. Beijing: Center for Health Statistics and Information, Beijing Municipal Health Commission, 2019.
  15. Zhao Y, Atun R, Oldenburg B, et al. Physical multimorbidity, health service use, and catastrophic health expenditure by socioeconomic groups in China: an analysis of population-based panel data. Lancet Glob Health. 2020;8(6):e840-e849. doi:1016/s2214-109x(20)30127-3
  16. O'Donnell O, van Doorslaer E, Wagstaff A, Lindelow M. Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their Implementation. Washington, DC: World Bank; 2008.
  17. O’Donnell O, van Doorslaer E, Rannan-Eliya A, et al. Explaining the Incidence of Catastrophic Payments for Health Care: Comparative Evidence from Asia. EQUITAP Working Paper No. 5. 2005.
  18. Si Y, Zhou Z, Su M, et al. Decomposing inequality in catastrophic health expenditure for self-reported hypertension household in Urban Shaanxi, China from 2008 to 2013: two waves' cross-sectional study. BMJ Open. 2019;9(5):e023033. doi:1136/bmjopen-2018-023033
  19. Wagstaff A, van Doorslaer E. Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993-1998. Health Econ. 2003;12(11):921-934. doi:1002/hec.776
  20. Wang Z, Li X, Chen M. Catastrophic health expenditures and its inequality in elderly households with chronic disease patients in China. Int J Equity Health. 2015;14:8. doi:1186/s12939-015-0134-6
  21. Pan XF, Xu J, Meng Q. Integrating social health insurance systems in China. Lancet. 2016;387(10025):1274-1275. doi:1016/s0140-6736(16)30021-6
  22. Chen G, Liu GG, Xu F. The impact of the urban resident basic medical insurance on health services utilisation in China. Pharmacoeconomics. 2014;32(3):277-292. doi:1007/s40273-013-0097-7
  23. Zhou Z, Su Y, Campbell B, et al. The financial impact of the 'zero-markup policy for essential drugs' on patients in county hospitals in western rural China. PLoS One. 2015;10(3):e0121630. doi:1371/journal.pone.0121630
  24. Zhou Z, Zhu L, Zhou Z, Li Z, Gao J, Chen G. The effects of China's urban basic medical insurance schemes on the equity of health service utilisation: evidence from Shaanxi province. Int J Equity Health. 2014;13:23. doi:1186/1475-9276-13-23
  25. Pan J, Tian S, Zhou Q, Han W. Benefit distribution of social health insurance: evidence from China's urban resident basic medical insurance. Health Policy Plan. 2016;31(7):853-859. doi:1093/hexapole/czv141
  26. Saif-Ur-Rahman KM, Anwar I, Hasan M, et al. Use of indices to measure socio-economic status (SES) in South-Asian urban health studies: a scoping review. Syst Rev. 2018;7(1):196. doi:1186/s13643-018-0867-6
  27. Gornick ME. Measuring the effects of socioeconomic status on health care. In: Guidance for the National Healthcare Disparities Report. Washington, DC: National Academies Press (US); 2002.
  28. Commission on Social Determinants of Health, WHO. A Conceptual Framework for Action on the Social Determinants of Health. Published July 13, 2010.
  29. Fu XZ. Financial protection effects of private health insurance: experimental evidence from Chinese households with resident basic medical insurance. Int J Equity Health. 2021;20(1):122. doi:1186/s12939-021-01468-5
  • Receive Date: 28 April 2022
  • Revise Date: 20 December 2022
  • Accept Date: 02 January 2023
  • First Publish Date: 08 January 2023