Universal health coverage in China: a serial national cross-sectional study of surveys from 2003 to 2018

Achieving universal health coverage (UHC) is one crucial target of the Sustainable Development Goals. However, consistent trends data for UHC evaluation in China are still scarce. The aim of our study was to provide a comprehensive assessment of UHC in China.In this serial cross-sectional study, we collected nationally representative data from the latest four rounds (2003, 2008, 2013, and 2018) of the National Health Service Surveys, with the aim of evaluating UHC in China. These surveys used multistage stratified cluster sampling covering all 31 provinces, autonomous regions, and municipalities in mainland China. Within each household, all members aged 15 years and older were interviewed. For children and adolescents aged younger than 15 years, their adult family members answered the questions for them. We constructed a UHC index following the WHO-recommended framework that included service coverage (nine prevention indicators and five treatment indicators) and financial protection (three indicators) dimensions. Bayesian regression models were done to investigate the trends in and projections of UHC index and indicators, with average annual percentage change (AAPC) and probabilities of achieving the 2030 WHO targets. Based on trends and projections, we counted population equivalents with UHC coverage. To examine the potential efficiency of financial investment, we quantified UHC performance based on government health expenditure (GHE) per capita. Finally, we explored the association between each UHC indicator and macroeconomic and health systems characteristics by using multiple regression.We sampled 57 023 households from 95 counties between September and October, 2003; 56 456 households from 94 counties between June and July, 2008; 93 613 households from 156 counties between August and October, 2013; and 94 076 households from 156 counties in September, 2018. A total of 901 182 individuals were involved in this study (193 689 in 2003, 177 501 in 2008, 273 688 in 2013, and 256 304 in 2018). Although the overall UHC increased from 44·0% (95% CI 43·0-44·9) in 2003 to 79·8% (79·2-80·3) in 2018 and is predicted to meet the 80% global target by 2030, the progress towards UHC has steadily slowed down nationally. Based on current projections, an estimated 105·8 (95% CI 27·3-189·1) million population equivalents would still not have UHC coverage in 2030. The treatment index showed a large increase over time from 2003 to 2018 (AAPC 4·9%, 2·9-7·2), with minimal disparities and all subgroups will achieve the target in the treatment domain by 2030 (possibilities higher than 90%). However, the prevention index presented poor performance with a small increase over time from 2003 to 2018 (AAPC 1·4%, 0·3-2·5) and sizable disparities across regions, urban-rural areas, and income (all p<0·0001). To achieve at least 80% UHC coverage, provinces would need to reach at least ¥445 in GHE per capita per year under maximum efficiency. However, large gaps between the observed and frontier UHC index, especially in several western provinces, indicated inefficiency. Furthermore, we found that primary health-care institutions were closely and positively related to UHC indicators especially in the prevention domain.Although considerable achievements have been made, the progress towards UHC is not keeping pace with the rapid society development in China. Considering an increased burden in non-communicable diseases and an ageing population, prioritising the efficacy of financial investment and optimising resource allocation by strengthening primary health care are necessary to achieve UHC in China.National Natural Science Foundation of China and National Health Commission of the People's Republic of China.