The impact of China’s primary health care reforms on utilisation, payments, and self-reported health: a quasi-experimental analysis of a middle-aged and older cohort 2011-2018
File(s)
Published version
Author(s)
Type
Journal Article
Abstract
Background Comprehensive health reforms aimed at
strengthening primary healthcare (PHC) are infrequently
adopted and often poorly evaluated in low-income and
middle-income countries. China launched a system-wide
PHC reform with a staggered roll-out between 2014
and 2018 with multiple components: (1) gatekeeping
via tiered reimbursement, (2) a family physician scheme
and (3) a two-way referral system between PHC facilities
and hospitals. This study examines the reform impacts
on health service utilisation, out-of-pocket expenditures,
health outcomes and health inequalities.
Methods The staggered roll-out of the reforms in 125
cities across China was identified using web-scraping.
Using longitudinal data (2011–2018) from the China Health
and Retirement Longitudinal Study (a cohort aged ≥45),
this study adopted a difference-in-differences method to
assess the reform’s impacts on: (1) visits to PHC facilities,
(2) hospitalisation, (3) out-of-pocket expenditures (OOPEs)
and (4) self-reported health. Subgroup analyses were
conducted by rural/urban populations and wealth quartiles.
Results The reform had small and short-lived impacts—a
7.8% increase in the probability of visiting PHC facilities
(95%CI 0.3 to 15.2), a 10.2% increase in reporting good
health (95%CI 0.6 to 19.8) and an 873.9 Chinese Yuan
(US$129.1) increase in average annual OOPEs (95%CI
57.9 to 1689.9) in the first year of reform implementation.
There was no impact on hospitalisation. Increases in PHC
utilisation were only found in rural and lower-income
populations.
Conclusions China’s PHC reforms had some modest,
temporary impacts on increasing primary care utilisation
and self-reported health. However, further interventions are
needed to transition away from the hospital-centric health
system and to increase financial protection and health
equity in China.
strengthening primary healthcare (PHC) are infrequently
adopted and often poorly evaluated in low-income and
middle-income countries. China launched a system-wide
PHC reform with a staggered roll-out between 2014
and 2018 with multiple components: (1) gatekeeping
via tiered reimbursement, (2) a family physician scheme
and (3) a two-way referral system between PHC facilities
and hospitals. This study examines the reform impacts
on health service utilisation, out-of-pocket expenditures,
health outcomes and health inequalities.
Methods The staggered roll-out of the reforms in 125
cities across China was identified using web-scraping.
Using longitudinal data (2011–2018) from the China Health
and Retirement Longitudinal Study (a cohort aged ≥45),
this study adopted a difference-in-differences method to
assess the reform’s impacts on: (1) visits to PHC facilities,
(2) hospitalisation, (3) out-of-pocket expenditures (OOPEs)
and (4) self-reported health. Subgroup analyses were
conducted by rural/urban populations and wealth quartiles.
Results The reform had small and short-lived impacts—a
7.8% increase in the probability of visiting PHC facilities
(95%CI 0.3 to 15.2), a 10.2% increase in reporting good
health (95%CI 0.6 to 19.8) and an 873.9 Chinese Yuan
(US$129.1) increase in average annual OOPEs (95%CI
57.9 to 1689.9) in the first year of reform implementation.
There was no impact on hospitalisation. Increases in PHC
utilisation were only found in rural and lower-income
populations.
Conclusions China’s PHC reforms had some modest,
temporary impacts on increasing primary care utilisation
and self-reported health. However, further interventions are
needed to transition away from the hospital-centric health
system and to increase financial protection and health
equity in China.
Date Issued
2025-01-01
Date Acceptance
2025-02-24
Citation
BMJ Public Health, 2025, 3 (1)
ISSN
2753-4294
Publisher
BMJ Publishing Group
Journal / Book Title
BMJ Public Health
Volume
3
Issue
1
Copyright Statement
© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. Published by BMJ Group.
License URL
Identifier
10.1136/bmjph-2024-001595
Publication Status
Published
Article Number
e001595
Date Publish Online
2025-03-23