Benefit equity of social health insurance in China and its provinces (2014–2020): implications for universal health coverage

Introduction China has increased fiscal input into social health insurance (SHI) schemes to achieve universal health coverage. Our study aimed to examine the equity of SHI benefits in the country and five representative provinces over the period of 2014–2020. Methods We analysed nationally and subnationally representative data from four waves (2014, 2016, 2018 and 2020) of the China Family Panel Studies. Benefit relative to consumption was assessed using concentration indices and concentration curves. We compared benefit distribution against health need across consumption quintiles. We further decomposed the change in the concentration index from 2014 to 2020. Results The national concentration index for SHI benefit was pro-rich but became substantially less so over time, falling from 0.262 in 2014 to 0.133 in 2020. Poorer quintiles suffered more ill health but received a smaller share of SHI benefits compared with the richer quintiles. All five provinces improved in benefit equity to varying degrees. Reduced disparity between employee and resident schemes, and use of hospitals as the usual source of care, accounted for 44.47% and 14.70%, respectively, of the national improvement in SHI benefit equity. Conclusion The benefit equity of SHI in China has improved, likely influenced by the narrowing funding gap between resident and employee scheme benefits. However, benefits remained skewed towards the richer groups with lower health need, revealing the resilience of an ‘Inverse Benefit Law’. We suggest risk-equalisation of SHI funds and coordinated reform in health financing and service delivery towards a greater focus on primary care.