During the last 2 decades, the population health status in

Transcription

1 ORIGINAL ARTICLE Rural and Urban Disparity in Health Services Utilization in China Meina Liu, MD, PhD,* Qiuju Zhang, MD, MPH,* Mingshan Lu, PhD, Churl-Su Kwon, MD, and Hude Quan, MD, PhD Objectives: To describe patterns in physician and hospital utilization among rural and urban populations in China and to determine factors associated with any differences. Methods: In 2003, the Third National Health Services Survey in China was conducted to collect information about health services utilization from randomly selected residents. Of the 193,689 respondents to the survey (response rate, 77.8%), 6429 urban and 16,044 rural respondents who were age 18 or older and reported an illness within the last 2 weeks before the survey were analyzed. Generalized estimating equations with a log link were used to assess the relationship between rural/urban residence and physician visit/hospitalization to adjust for respondents clustered at the household level. Results: About half of respondents did not see a physician when they were ill. Rural respondents used physicians more than urban respondents (52.0% vs. 43.0%, P 0.001) and used hospitals less (7.6% vs. 11.1%, P 0.001). Factor associated with increased physician utilization included residing in rural areas among majority Chinese (ie, Han) rate ratio (RR), 1.21; 95% confidence interval (95% CI), , residing 3 km away from the medical center (RR, 1.16; 95% CI, ), or being uninsured (RR, 1.38; 95% CI, ). Rural minority Chinese visited physicians significantly less than urban minority Chinese (RR, 0.90; 95% CI, ). Hospital utilization was significantly lower among rural males (RR, 0.84; 95% CI, ), rural seniors (age, 65; RR, 0.64; 95% CI, ), rural respondents with low education (RR, 0.70; 95% CI, for illiterate), or rural insured respondents (RR, 0.86; 95% CI, ) than hospitalization among urban counterparts. From the *Department of Biostatistics, School of Public Health, Harbin Medical University, Harbin, China; Departments of Economics, Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Lister Hospital, Corey s Mill Lane, Stevenage, Hertfordshire, United Kingdom; Research Institute of Economics and Management, Southwestern University of Finance and Economics, Chengdu, China; and Centre for Health and Policy Studies, University of Calgary, Calgary, Alberta, Canada. Supported by a Population Health Investigator Award from the Alberta Heritage Foundation for Medical Research, and by a New Investigator Award from the Canadian Institutes of Health Research, Canada (to H.Q.), and Institute of Health Economics, Alberta (to M.L.). Reprints: Dr. Hude Quan, Department of Community Health Sciences, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, Canada T2N 4N1. hquan@ucalgary.ca. Copyright 2007 by Lippincott Williams & Wilkins ISSN: /07/ Conclusions: Three national approaches should be considered in reforming the healthcare system in China: universal insurance coverage, higher amounts of insurance coverage, and increasing the population s level of education. In addition, access issues in remote areas and by rural minority Chinese population should be addressed. Key Words: health services, healthcare system, health insurance, China (Med Care 2007;45: ) During the last 2 decades, the population health status in China significantly improved along with its dramatic economic development. In the 21st century, life expectancy at birth reached 71.4 years. 1 However, a large disparity in rural and urban health status exists. Compared with urban residents (about 561 million), infant mortality in the rural population (about 745 million) is over 2 times higher (11.3 of 1000 vs of 1000) and life expectancy is 6 years less (75.2 years vs years). 1,2 Although many factors, particularly socioeconomic status, account for such a large gap, access to the healthcare system is a pivotal factor. 3 The healthcare system was profoundly reformed in the 1980s under the national climate of economic profit as priority. A publicly funded and government-managed system was transited to a market-oriented system, 4 resulting in the current Chinese healthcare system serving a small proportion of the population that has or can afford health insurance. For the urban population, the dominate form of health insurance is employment-based, including the Labor Insurance Program and government employee insurance. These 2 forms of insurance provide partial or no coverage for dependents. 5 Furthermore, with increasing utilization of costly diagnostics, high-technology surgery, and imported drugs, many employers no longer provide full insurance coverage even to the employee. In fact, the Medical Saving Account scheme is becoming increasingly popular in urban China, whereby employers provide employees with a fixed amount of money per month to cover basic health services and employees are responsible for the remaining expenditures. 6,7 For the rural population, the Cooperative Medical System, a form of community-based health insurance, has collapsed, leaving private health insurance the only option. 5,8 Although different degrees of coverage are available through private health insurance, the premiums for extensive coverage are expensive and Medical Care Volume 45, Number 8, August

2 Meina et al Medical Care Volume 45, Number 8, August 2007 cannot be afforded by most of the rural and even the urban populations. This leaves the vast rural population, children, and those who are unemployed or retired uninsured. 5,8 Because rural residents are much poorer than urban residents on average, financial barriers may widen the disparity between urban and rural residents access to healthcare services even further. In recent years, the Chinese government has been exploring new financing models in rural areas, hoping to reestablish community-based health insurance; however, these efforts largely remain at the research and experimental stages, with some pilot projects being launched and evaluated. 8,9 Previous studies about the Chinese healthcare system have been limited to examining health insurance and healthcare in certain areas in China, with little empirical evidence on the rural and urban disparity in health service utilization. 6,10 19 A growing number of studies have been conducted to address geographic variation in access to healthcare services and outcomes because geographic location may influence a patient s chance of receiving healthcare ;to fill this knowledge gap in China, we conducted this unique study using a Chinese national survey to describe patterns of rural and urban physician and hospital services utilization, and to determine factors associated with any observed differences. Our study provides evidence to health policy makers on whether rural and urban residents in China access the healthcare system equally, and proposes approaches to eliminate unequal access. The elimination of disparities in health, including healthcare, has been identified as a target to improve population health status in several countries. 23 METHODS Study Population We used data from the China Third National Health Services Survey, which collected data through face-to-face interviews from September 18 to October 20, Of the 193,689 respondents surveyed, we excluded individuals who were 8 years old and included only those with a demonstrated need for healthcare, that is, those reporting an illness within the last 2 weeks before the survey (Fig. 1). This resulted in a total of 22,473 (6429 urban and 16,044 rural) respondents in our sample after excluding 168 respondents with missing values. The survey used a multiple-stage cluster sampling method to randomly select the sample. The entire country, except Hong Kong and Macau, was clustered by the government administrative geographic system (ie, city, county, town, and village). A total of 95 cities or counties, 475 towns, and 950 villages were randomly selected. The selected cities were further divided into neighborhood communities (the smallest unit of administration in an urban area). In each community or village, 60 households were randomly selected, resulting in about 57,000 households. All family members were invited to participate in the face-toface interview. The same sampling method had been used in the previous 2 National Health Services Surveys. Analyses of previous surveys suggest that this sampling method is adequate to generate a nationally representative sample. 24 The survey respondent age and sex composition was comparable with the 2000 census. 768 FIGURE 1. Sample size. Medical doctors conducted the survey. Before the survey, interviewers were trained and practiced interviewing. After training, their understanding and knowledge about the survey method and content were examined through testing. During the survey, interviewers visited each household up to 3 times on different days. Interviewers explained the purposes and confidentiality of the survey, and then invited family members to participate. Respondents could choose not to participate; their participation in the survey was accepted as oral consent. The completeness of questionnaires was checked by a district survey manager at the end of every day. If there was missing information on the survey, individuals were resurveyed if possible. The survey response rate was 77.8%. After the survey, 5% of households were randomly selected and resurveyed on 14 questions to examine survey quality; the agreement was 95%. 25 Dependent Variables The dependent variables included physician visit(s) within the last 2 weeks and hospitalization(s) within the last 1 year. The survey asked, Have you received any treatment during the last 2 weeks? Those who received treatment were further asked, What type of treatment? and provided 3 choices: (1) self-treatment without physician visit, (2) physician visit, or (3) a combination of self-treatment and physician visit. We grouped respondents who chose either physician visit or a combination of self-treatment and physician visit as the physician users. The remaining individuals, those who chose either selftreatment only or not receiving any treatment, were classified as nonphysician users Lippincott Williams & Wilkins

3 Medical Care Volume 45, Number 8, August 2007 Health Services Utilization in China Hospitalization in the last year was determined based on the survey question, How many times were you hospitalized during the last one year due to any reasons, such as illness, injury, physical check-up, delivery, et al? From this question, we categorized respondents into hospital users (1 or more hospitalization) and nonhospital users. Hospitalization was defined as staying in hospital at least 1 night. Independent Variable Independent variables were selected based on the behavioral model of health service utilization developed by Aday and Andersen. 26,27 This model is one of the most frequently used frameworks in North America as well as in China for analyzing the factors associated with patient utilization of healthcare services and access to healthcare. Using this model, we classified age, sex, ethnicity, and marital status as predisposing factors; rural/urban, geographic region, education, distance from home to the closest medical center, and health insurance status (insured or not) as enabling factors; and self-perceived severity of illness and presence of physician-diagnosed chronic diseases within the last 6 months as need factors. China was geographically grouped into urban (ie, cities) or rural areas (ie, town or villages) after the governmental administration system, as well as Eastern China, mid-china, and Western China based on economic development status. Eastern China is the most developed region, mid-china is less developed, and Western China the least. Ethnicity was grouped into Han or minority. Among the 56 ethnicities in China, Han ethnicity is the largest, accounting for 95% of the population. The survey asked respondents: How far is the nearest medical center or clinic from your home? Possible responses were as follows: 1, 2, 3, 4, and 5 km or more. Health insurance status was defined according to survey questions about coverage by social welfare, private health insurance, or both. Presence or absence of individual chronic disease was recorded. Chronic disease referred to disease diagnosed by medical doctors as chronic disease in the last 6 months before the survey, or chronic disease that was diagnosed more than 6 months before the survey but reoccurred with the last 6 months and received treatment. Nonphysician-diagnosed chronic disease was not included because the validity of self-diagnosed medical conditions depends on the level of the respondent s knowledge and their perceptions on the definition of disease and health. Physician-diagnosed chronic disease was further confirmed through self-reported type of hospital where the diagnosis was received (including community clinics, county hospital, city hospital, provincial hospital, military hospital, and others). Self-perceived illness severity was measured within the categories of minor, mild, severe, and unsure. Statistical Analysis Descriptive statistics were used to test the statistical differences in sociodemographic characteristics, physician visits, and hospitalizations between rural and urban residents. Frequencies of variables in the survey were not weighted because sampling weights were not available. Stratified analyses were conducted for the independent variables to determine whether the association between rural/urban residence and health services utilization differed across strata (ie, effect modification). Finally, multiple binomial regression with a log link was used to assess whether the relationship between rural/urban residence and physician visit/hospitalization was confounded or modified by other characteristics. Clustering of individuals within family was adjusted for using the repeated measure function in SAS 9.1 Proc GENMOD. 31,32 Two multiple binomial regression models, 1 for physician visit and another for hospitalization were fitted after a 3-step modeling strategy. Step 1 was to form a main effect model with physician visit/hospitalization as the dependent variable, rural/urban as the exposure independent variable, and sex, age, ethnicity, marital status, education, distance from home to medical center, health insurance, severity of illness, chronic disease, and geographic region as the remaining independent variables. Step 2 was to assess effect modifications. All 2-factor modification terms involving rural/urban and other independent variables were produced and fitted into the main effect model. Exclusion of the 2-factor modification terms from the model in sequential fashion was based on the log-likelihood test and biologic plausibility. Step 3 was to remove variables that did not meaningfully alter the rate ratios (RRs) (also called prevalence ratio or risk ratio) for rural/urban residence or were not significantly associated with physician visit/hospitalization. The retained variables and modification terms in the parsimonious model were used to assess the association between rural/urban and physician visit/hospitalization. The data were analyzed at the health information center of the Ministry of Health in Beijing. Confidentiality of the survey was protected by storing the data on password-protected computers at the Ministry, removal of personal identifiable information (such as name and address) from the database available for researchers, and examining analysis outputs for release of aggregated data by the center staff. RESULTS Descriptive Analysis Compared with urban respondents, rural respondents were more likely to be male, younger, an ethnic minority versus Han, unmarried, less educated, and residents in a remote area or Western China (Table 1), but were less likely to have health insurance (12.6% vs. 62.5%, P 0.001) and physician-diagnosed chronic disease (52.3% vs. 72.0%, P 0.001). About half of the respondents did not see a physician when they were ill (Table 2), but many respondents treated illnesses by themselves without physician consultations (32.3% for rural and 47.0% for urban). The proportion of self-treatment was correlated to level of education (49.7% for college or above, 42.3% for senior high, 38.6% for junior high, 34.8% for elementary, and 32.1% for illiterate). Rural respondents visited physicians more than urban respondents (52.0% vs. 43.0%, P 0.001), but hospitals less (7.6% vs. 11.1%, P 0.001; Table 3). The stratified analysis by rural/urban and remaining independent variables is pre Lippincott Williams & Wilkins 769

4 Meina et al Medical Care Volume 45, Number 8, August 2007 TABLE 1. Characteristics of Survey Respondents Who Variables Rural (%) N 16,044 Urban (%) N 6429 Gender, male 7276 (45.4) 2734 (42.5) Age, yr (48.0) 2045 (31.8) (31.6) 1917 (29.8) (20.4) 2467 (38.4) Ethnicity, Han Chinese 13,381 (83.4) 5840 (90.8) Marital status Married 13,373 (83.3) 5096 (79.3) Unmarried 700 (4.4) 251 (3.9) Divorced 110 (0.7) 147 (2.3) Widow 1861 (11.6) 935 (14.5) Education Illiterate 5726 (35.7) 1086 (16.9) Elementary school 5529 (34.5) 1382 (21.5) Junior high school 3833 (23.9) 1717 (26.7) Senior high school 726 (4.5) 966 (15.0) College/university or 230 (1.4) 1278 (19.9) higher Distance from home to 14,105 (87.9) 6165 (95.9) medical center 3 km Having health insurance 2023 (12.6) 4019 (62.5) Self perceived illness as 4120 (25.7) 1607 (25.0) being severe Presence of physiciandiagnosed 8398 (52.3) 4627 (72.0) chronic disease Geographic region Eastern China 5014 (31.3) 2473 (38.5) Mid-China 3853 (24.0) 1818 (28.3) Western China 7177 (44.7) 2138 (33.2) TABLE 2. Illness Management Among Rural and Urban Residents Who Reported Illness in the 2 Weeks Before the Survey Rural (%) N 16,044 sented in Table 3. Differences between rural and urban residents in physician visits depended on ethnicity, marital status, and distance from home to medical center; differences in hospital utilization depended on age, ethnicity, marital status, education, distance from home to medical center, insurance status, and presence of chronic disease. Multivariate Analysis After adjusting for the independent variables listed in Table 1, rural respondents were still more likely to visit a P Urban (%) N 6429 Self-treatment without physician visit 5180 (32.2) 3022 (47.0) Physician visit 6958 (43.4) 2111 (32.9) Self-treatment and physician visit 1379 (8.6) 652 (10.1) No treatment 2527 (15.8) 644 (10.0) 770 physician risk-adjusted RR, 1.16; 95% confidence interval (95% CI), , Table 4), but tended to use the hospital less than urban respondents (RR, 0.94; 95% CI, ; Table 4). There were significant subpopulation disparities in rural and urban health services utilization (Tables 5 and 6). Rural residents visited physicians significantly more than urban residents among respondents who were Han Chinese (RR, 1.21; 95% CI, ; Table 6), resided less than 3 km away from a medical center (RR, 1.16; 95% CI, ), or uninsured (RR, 1.38; 95% CI, ). Rural minority Chinese respondents visited physicians significantly less than urban minority Chinese respondents (RR, 0.90; 95% CI, ). Hospital utilization was significantly lower among rural male (RR, 0.84; 95% CI, ), rural seniors (age 65; RR, 0.64; 95% CI, ), and rural respondents with low education (RR, 0.70; 95% CI, for illiterate) or insured (RR, 0.86; 95% CI, ) than hospitalization among urban counterparts. DISCUSSION Our analysis of the China Third National Health Services Survey highlighted that about half of respondents did not visit physicians when they were ill in the 2 weeks before the survey; rural residents used physician services more but tended to use hospital services less than urban residents. The rural and urban disparity in hospital service utilization was particularly evident in male, senior, illiterate, or insured populations. Physician services utilization has been declining in the last decade in China. The previous 2 National Health Services Surveys revealed that of urban residents who reported illness in the last 2 weeks, 59% saw a physician in 1993 and 50% in The percentage dropped to 43% in the Of multiple factors related to the decline, increases in fees for healthcare services and low insurance coverage may be the most essential. Patients generally see physicians at outpatient hospital clinics for diagnostic tests and treatment, and at community medical centers for follow-up, rehabilitation, and treatment of minor medical conditions. With the transition in national policy from social equality to capitalism, the traditional health policy of public funding to healthcare, prevention first and health for all has been neglected. Medical clinics and hospitals set economic profits as their priority, and the fee for physician visits greatly varies by hospitals and by physicians qualifications. To pursue revenue, hospitals purchase expensive diagnostic equipment and build costly wards, whereas physicians prescribe high-profit and expensive imported pharmaceuticals as well as high-profit diagnostic and laboratory tests. For urban residents, the average cost was 219 Yuan (Chinese currency) per physician visit (including diagnostics and medication) and 7606 Yuan per hospitalization in 2003, an increase of 85% and 88% over the average cost in For rural residents, the average cost in the same year was 91 Yuan per physician visit (including diagnostics and 2007 Lippincott Williams & Wilkins

5 Medical Care Volume 45, Number 8, August 2007 Health Services Utilization in China TABLE 3. Physician Visit in the Last 2 Weeks and Hospitalization Within 1 Year Among Rural and Urban Residents Who Physician Visit Hospitalization Rural n (%) Urban n (%) P Rural n (%) Urban n (%) P Overall 8337 (52.0) 2763 (43.0) (7.6) 713 (11.1) Age, yr (53.3) 899 (43.5) (7.1) 134 (6.6) (51.8) 789 (41.2) (8.6) 178 (9.3) (48.9) 1085 (44.0) (7.5) 401 (16.3) Gender Male 3706 (50.9) 1158 (42.4) (7.8) 360 (13.2) Female 4631 (52.8) 1605 (43.4) (7.5) 353 (9.6) Ethnicity Han Chinese 7076 (52.9) 2415 (41.4) (7.3) 660 (11.3) Minority Chinese 1261 (47.4) 348 (59.1) (9.3) 53 (9.0) Marital status Married 6970 (52.1) 2199 (43.2) (7.8) 562 (11.0) Unmarried 377 (53.9) 107 (42.6) (6.3) 17 (6.8) Divorced 49 (44.6) 57 (38.8) (7.3) 15 (10.2) Widow 941 (50.6) 400 (42.8) (6.7) 119 (12.7) Education Illiterate 2996 (52.3) 520 (47.9) (7.1) 119 (11.0) Elementary school 2890 (52.3) 617 (44.7) (8.0) 172 (12.5) Junior high school 1969 (51.4) 700 (40.8) (7.4) 174 (10.1) Senior high school 366 (50.4) 411 (42.6) (8.8) 100 (10.4) College or university 116 (50.4) 516 (40.3) (12.6) 148 (11.6) Distance from home to medical center 3 km 7328 (52.0) 2627 (42.6) (7.5) 691 (11.2) km 1009 (52.0) 136 (51.5) (8.2) 22 (8.3) Health insurance Insured 1059 (52.4) 1879 (46.8) (7.8) 514 (12.8) Uninsured 7278 (51.9) 884 (36.7) (7.6) 199 (8.3) Self perceived illness Severe 2638 (64.0) 961 (59.8) (13.6) 313 (19.5) Nonsevere 5699 (47.8) 1802 (37.4) (5.6) 400 (8.3) Presence of physician diagnosed chronic disease Absence 4098 (53.6) 776 (43.1) (4.3) 94 (5.2) Presence 4239 (50.5) 1987 (42.9) (10.6) 619 (13.4) Geographic region Eastern China 2691 (53.7) 1152 (46.6) (6.8) 266 (10.8) Mid-China 1946 (50.5) 573 (31.5) (7.1) 217 (11.9) Western China 3700 (51.6) 1038 (48.6) (8.5) 230 (10.8) medication) and 2649 Yuan per hospitalization in 2003, a 103% and 73% increase over To put this into perspective, the fee for 1 hospitalization is approximately equivalent to 6 months average income of a labor worker in China. Such expensive healthcare compels low-income patients to stay away from hospitals. Also, health insurance premiums are expensive and out of reach for lowincome patients, further restricting access. In our sample, 87% of rural and 37% of urban residents were uninsured. Our findings of low physician visits among seniors, minority Chinese, and residents in less-developed regions (mid and Western China) as well as high physician visits among the insured support the argument that financial barriers restrict access to healthcare (Table 4). Our study demonstrated that many patients (47% rural and 32% urban residents) took self-treatment (such as taking medication stored at home or purchased at drug stores) without consulting a physician. Prescribed drugs have been introduced in China just recently. Before that, a prescription was not required to purchase medication at a pharmacy Lippincott Williams & Wilkins 771

6 Meina et al Medical Care Volume 45, Number 8, August 2007 TABLE 4. Rate Ratio in Physician Visit in the Last 2 Weeks and Hospitalization Within 1 Year Among Respondents Who Physician Visit Rate Ratio (95% CI) Hospitalization Rate Ratio (95% CI) Rural/urban 1.16 ( ) 0.94 ( ) Gender Female/male 1.02 ( ) 0.94 ( ) Age, yr 50 64/ ( ) 1.11 ( ) 65/ ( ) 1.40 ( ) Ethnicity Minority/Han 0.94 ( ) 1.09 ( ) Marital status Unmarried/married 1.02 ( ) 0.95 ( ) Divorced/married 0.88 ( ) 1.00 ( ) Widow/married 0.98 ( ) 0.86 ( ) Education Elementary/illiterate 1.00 ( ) 1.30 ( ) Junior high/illiterate 0.96 ( ) 1.35 ( ) Senior high/illiterate 0.96 ( ) 1.48 ( ) College or 0.92 ( ) 1.52 ( ) university/illiterate Distance from home to medical center 3 kilometer/ 0.99 ( ) 1.00 ( ) 3 kilometer Health insurance Insured/uninsured 1.09 ( ) 1.14 ( ) Self perceived severity of illness Severe/unsevere 1.42 ( ) 2.22 ( ) Presence of physician diagnosed chronic disease Presence/absence 0.90 ( ) 2.15 ( ) Geographic region Mid/Eastern 0.87 ( ) 1.08 ( ) Western/Eastern 0.95 ( ) 1.12 ( ) Individuals would purchase drugs based on their own knowledge of their illness and the effectiveness of these drugs in treating their illness. There was no mechanism in place to monitor the self-administration of medications and safety of individuals choosing to do so. When individuals did not become better after self-treatment or perceived their illness as being severe, they would go to visit a physician. This is supported by our findings that self-perceived severity of illness is a strong predictor of physician visit and hospitalization. Moreover, the correlation between the level of education and self-treatment further suggests that patients with a high level of health knowledge were more likely to turn to self-treatment. Long-term consequences of self-treatment on population health could be numerous, such as misusing medication, worsening disease severity, causing complications, delaying the optimal timing of effective treatments, and impairing quality of life. These consequences could increase disease 772 TABLE 5. Rate Ratio for Rural vs. Urban Residents in Physician Visit in the Last 2 Weeks Among Respondents Who Physician Visit Rate Ratio (95% CI)* Rural/urban among Han Chinese respondents 1.21 ( ) Rural/urban among minority Chinese 0.90 ( ) respondents Rural/urban among respondents with distance 1.16 ( ) 3 kilometer from home to medical care center Rural/urban among respondents with distance 0.99 ( ) 3 kilometer from home to medical care center Rural/urban among respondents insured 0.99 ( ) Rural/urban among respondents uninsured 1.38 ( ) *Rate ratio for rural vs. urban was adjusted for sex, age, ethnicity, martial status, education, distance from home to medical center, health insurance, severity of illness, chronic disease, and geographic region. TABLE 6. Rate Ratio for Rural vs. Urban Residents in Hospitalization Within 1 Year Among Respondents Who Hospitalization Rate Ratio (95% CI)* Rural/urban among males 0.84 ( ) Rural/urban among females 1.06 ( ) Rural/urban among respondents age 1.20 ( ) Rural/urban among respondents age 0.64 ( ) 65 Rural/urban among illiterate 0.70 ( ) respondents Rural/urban among respondents with 0.85 ( ) elementary education Rural/urban among junior or senior 1.18 ( ) high school education Rural/urban among respondents with 1.37 ( ) college/university or higher education Rural/urban among respondents 0.83 ( ) insured Rural/urban among respondents 1.07 ( ) uninsured *Rate ratio for rural vs. urban was adjusted for sex, age, ethnicity, martial status, education, distance from home to medical center, health insurance, severity of illness, chronic disease, and geographic region. burden and impair population health. Self-treatment could also cause challenges in monitoring infectious and epidemic diseases. Our results highlighted that rural residents used physicians more and hospitals less than urban residents. The first possible explanation for these findings is that drugs are generally available only at clinics in rural areas. Therefore, residents in these areas see a physician to obtain a prescription for medication. The relatively lower cost of physician visits in rural areas may promote physician utilization as well. The second possible explanation is that the cost to travel from 2007 Lippincott Williams & Wilkins

7 Medical Care Volume 45, Number 8, August 2007 Health Services Utilization in China a village to a town with a pharmacy is a deterrent, compared with the cost of seeing a physician in the local clinic and filling a prescription there. In contrast, residents in urban areas have drugs available to them at local pharmacies and the cost of seeing a physician is much higher compared with that in rural areas. Therefore, urban residents with insurance coverage are as likely as rural residents to see physicians, but urban residents without insurance may choose drugs at pharmacies without physician consultation. The third possible explanation is that rural residents primarily rely on outpatient treatment and accept hospitalization only as a last resort because of its high cost. Our study demonstrated that uninsured rural residents used physician services significantly more but used hospitals equally compared with uninsured urban residents. Of variables associated with hospitalization (ie, age, marital status, education, insurance, severity of disease, presence of chronic disease, and geographic region), education and insurance are 2 modifiable factors (Table 4). These findings indicated that promoting access to healthcare should focus on reforming the Chinese healthcare system towards universal healthcare coverage, and promoting a higher national educational level. Education is a proxy of socioeconomic status. 34 Patients with a high level of education would likely be employed and insured because health insurance premiums are partly covered by employers. However, a majority of rural residents are less educated and uninsured. We found that rural insured residents used physician services equally but used hospitals significantly less compared with insured urban residents (Tables 5 and 6). The amount of insurance might be lower for rural residents than urban residents, and thus be insufficient to cover expensive hospital services. Unfortunately, our data do not allow us to quantify the actual coverage of insurance. Our study has some important limitations. Data were collected through a survey and therefore subjected to errors in recall. Also, the cross-sectional nature of the survey makes it impossible to establish a causal relationship between urban/rural residence and health services utilization. We studied physician and hospital utilization and did not assess quality of care, or access to other sectors of the healthcare system, such as preventive services. Health services utilization is influenced by supply. We measured the supply factor using distance from home to the nearest medical center. However, other supply factors (such as number of doctors, community health programs, and type of medical center) were not assessed. In conclusion, rural and urban disparities in utilization of healthcare exist in China. Rural residents use physicians more but hospitals less than urban residents, particularly among uninsured populations. Although our study was unable to directly assess the role of insurance quantity on these utilization patterns, reforming the healthcare system towards universal insurance coverage and increasing the amount insured, while increasing the population s education level, is an approach that should be considered at the national level. In addition, access issues in remote areas and by rural minority Chinese population should be addressed. This study only analyzed utilization of healthcare services; assessment of quality of care is imperative for future research. ACKNOWLEDGMENTS The authors thank the China Ministry of Health for providing the data for the analysis. REFERENCES 1. Information Centre, Health Ministry of China. China Health Development Report, in Chinese. Beijing, China: Health Ministry of China; China Statistics Department. Statistics of 1% National Sample, Beijing, China: China Statistics Department; Zimmer Z, Kwong J. Socioeconomic status and health among older adults in rural and urban China. J Aging Health. 2004;16: Research Project Team of China Development Research Center (CDRC) under the State Council. Evaluation and recommendation to China healthcare system reform. China Development Evaluation and Discussion [in Chinese]. 2005;(Suppl 1): Hsiao WC. The Chinese health care system: lessons for other nations. Soc Sci Med. 1995;41: Liu Y, Hsiao WC, Eggleston K. Equity in health and health care: the Chinese experience. Soc Sci Med. 1999;49: Liu G, Nolan B, Wen C. Urban Health Insurance and Financing in China. Washington, DC: The World Bank; Zhang L, Wang H, Wang L, et al. Social capital and farmer s willingness-to-join a newly established community-based health insurance in rural China. Health Policy. 2006;76: Liu Y, Rao K. Providing health insurance in rural china: from research to policy. J Health Polit Policy Law. 2006;31: Gao J, Qian J, Tang S, et al. Health equity in transition from planned to market economy in China. Health Policy Plan. 2002;17(suppl): Wang H, Yip W, Zhang L, et al. Community-based health insurance in poor rural China: the distribution of net benefits. Health Policy Plan. 2005;20: Henderson G, Jin S, Akin J, et al. Distribution of medical insurance in China. Soc Sci Med. 1995;41: Liu GG, Zhao Z, Cai R, et al. Equity in health care access to: assessing the urban health insurance reform in China. Soc Sci Med. 2002;55: Akin JS, Dow WH, Lance PM. Did the distribution of health insurance in China continue to grow less equitable in the nineties? Results from a longitudinal survey. Soc Sci Med. 2004;58: Gu X, Bloom G, Tang S, et al. Financing health care in rural China: preliminary report of a nationwide study. Soc Sci Med. 1993;36: Gao J, Tang S, Tolhurst R, et al. Changing access to health services in urban China: implications for equity. Health Policy Plan. 2001;16: Wu J, Liu Y, Rao K, et al. Education-related gender differences in health in rural China. Am J Public Health. 2004;94: Henderson GE, Akin JS, Hutchinson PM, et al. Trends in health services utilization in eight provinces in China, Soc Sci Med. 1998;47: Akin JS, Dow WH, Lance PM, et al. Changes in access to health care in China, Health Policy Plan. 2005;20: Seidel JE, Beck CA, Pocobelli G, et al. Location of residence associated with the likelihood of patient visit to the preoperative assessment clinic. BMC Health Serv Res. 2006;6: Piette JD. Moos RH. The influence of distance on ambulatory care use, death, and readmission following a myocardial infarction. Health Serv Res. 1996;31: Meden T, St John-Larki C, Hermes D, et al. MSJAMA. Relationship between travel distance and utilization of breast cancer treatment in rural northern Michigan. JAMA. 2002;287: Institute of Medicine. Unequal Treatment: What HealthCare Providers Need to Know About Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy of Sciences; China Ministry of Health. The Third National Health Services Survey Design in Chinese. Beijing, China: China Ministry of Health; Lippincott Williams & Wilkins 773

8 Meina et al Medical Care Volume 45, Number 8, August Chai M, Yao K, Qian J, et al. Three National Health Services Surveys: trend analysis of major diseases in Chinese. China Hosp Stat. 2005; 12: Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974;9: Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36: Lin JD, Wu JL, Lee PN. Healthcare needs of people with intellectual disability in institutions in Taiwan: outpatient care utilization and implications. J Intellect Disabil Res. 2003;47: Guo S, Wang L, Yan R. Utilization of health service in women with reproductive tract infections in urban and rural areas in Chinese. Zhonghua Liu Xing Bing Xue Za Zhi. 2002;23: Ruy H, Young WB, Kwak H. Differences in health insurance and health service utilization among Asian Americans: method for using the NHIS to identify unique patterns between ethnic groups. Int J Health Plann Manage. 2002;17: McNutt LA, Wu C, Xue X, et al. Estimating the relative risk in cohort studies and clinical trials of common outcomes. Am J Epidemiol. 2003;157: Spiegelman D, Hertzmark E. Easy SAS calculations for risk or prevalence ratios and differences. Am J Epidemiol. 2005;162: The Centre for Statistics and Health Information MoHC. Abstract of the report on the 3rd national health services investigation and analysis in Chinese. Chin Hosp. 2005;9: Lahelma E, Martikainen P, Laaksonen M, et al. Pathways between socioeconomic determinants of health. J Epidemiol Community Health. 2004;58: Lippincott Williams & Wilkins