The heterogeneous effects of China's hierarchical medical system reforms on health service utilisation and health outcomes among elderly populations: a longitudinal quasi-experimental study

BackgroundSystem-wide, comprehensive, primary health care (PHC)-oriented health reforms are infrequently introduced in low-income and middle-income countries and often poorly studied. China initiated a large-scale reform in 2015 that included multiple policies: partial gatekeeping, a family physician scheme, and increased system integration. These policies aimed to build a PHC-oriented health system and improve primary care utilisation. This study assessed the heterogeneous effects of the reforms on health service utilisation and health outcomes across regions and over time.MethodsIn this longitudinal quasi-experimental study, we used longitudinal data (2011–18) from a national survey on elderly populations and governmental yearbooks. This study exploits the staggered rollout of the reforms at the city level identified using web-scrapping. We employed an event study design to assess reform effects on (1) visits to PHC facilities, (2) admissions to hospital, (3) out-of-pocket expenditures (OOPEs), and (4) self-reported health. Models were adjusted for city and time fixed effects, along with demographic and socioeconomic characteristics at individual and provincial levels. Analysis was separated into rural and urban populations.Findings18 988 Chinese individuals aged 45 and older (mean age 60·4 years [SD 10·3], 9990 [52·6%] women, 8998 [47·4%] men) were included in the analysis. The reform was associated with increasing odds of visiting PHC facilities among rural populations, which became stronger in the 2 years after the reform (adjusted odd ratio [aOR] 1·35, 95% CI 1·02–1·84, p=0·0374; absolute effect sizes [probability] 3%) before it faded. Meanwhile, urban populations were unaffected (from aOR 1·22, 0·82–1·81 to 0·89, 0·50–1·57). The reform did not have a significant effect on admission to hospital (rural: from 0·97, 0·72–1·31 to 1·47, 0·85–2·55; urban: from 1·00, 0·69–1·43 to 1·59, 0·76–3·30) or OOPEs (rural: from 260·32 Chinese Yuan, 95% CI –6·34 to 526·97, to 693·07 Chinese Yuan, –102·96 to 1489·09; urban: from 235·37 Chinese Yuan, –405·10 to 875·83, to 859·93 Chinese Yuan, –199·02 to 1918·88). Urban populations reported higher self-reported health after the reforms than the year before the reforms (1·50, 1·12–2·01, p=0·0002; 5%).InterpretationSystem-wide PHC-oriented reforms might contribute to short-term increases in primary care utilisation in elderly populations with implications for urban–rural inequalities. Effects on financial protection and health inequality were limited. Efforts in improving the accessibility and quality of primary care in deprived areas are indispensable to addressing the persistent inverse care law and to achieving Universal Health Coverage for all countries.FundingNone.