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Urban-rural disparities in health care utilization among Chinese adults from 1993 to 2011

BMC Health Services ResearchBMC series – open, inclusive and trusted201818:102

https://doi.org/10.1186/s12913-018-2905-4

Received: 28 February 2017

Accepted: 31 January 2018

Published: 9 February 2018

Abstract

Background

Despite economic growth and improved health outcomes over the past few decades, China still experiences striking urban-rural health inequalities. Urban and rural residents distinguished by the hukou system may experience profound disparities because of institutional effect. The aim of this study is to estimate trends in urban-rural disparities in self-care, outpatient care, and inpatient care utilization from a perspective of the hukou system.

Methods

Data were extracted from the seven latest waves of the China Health and Nutrition Survey (CHNS). We used the hukou system to distinguish between urban and rural residents. Chi-square tests were performed to examine urban-rural gaps in self-care, outpatient care, and inpatient care utilization. Multinomial logistic regression was employed to confirm these disparities and to explore whether the urban-rural gaps have narrowed or widened from 1993 to 2011 once known determinants of utilization are taken into account according to Andersen/Aday’s Health Behaviour Model.

Results

The urban-rural disparities were evident after controlling for confounding variables: urban adults were 3.24 (p < 0.05), 2.23 (p < 0.1), and 4.77 (p < 0.01) times more likely to choose self-care vs. no care, outpatient care vs. no care, and inpatient care vs. no care than their rural counterparts, respectively. The results showed upward trends in self-care, outpatient care, and inpatient care utilization from 2004 to 2011. The urban-rural gaps in health care utilization gradually narrowed during the period of 1993–2011. The hukou distinctions of self-care, outpatient care, and inpatient care in 2011 were only 33.3%, 35.5%, and 9.6% of that in 1993, respectively.

Conclusions

Although rural residents were underutilizing health care when compared to their urban counterparts, the significant decrements in urban-rural disparities reflect the positive effect of the on-going health system reform in China. To maintain an equitable distribution of health care utilization, policy makers need to be aware of challenges due to aging problems and health expenditure increment.

Keywords

Urban/ruralHukou systemHealth care seeking behaviourDynamic trendsChina

Background

Ensuring equitable access to health services is an enduring concern for health system planners and policy-makers [1]. Despite economic growth and improved health outcomes over the past few decades in China, previous studies indicate significant urban-rural inequality in health related issues such as health care resources [2, 3], health outcomes in adults and children [36], and prevalence of certain diseases [712]. Compared with urban residents, infant mortality in the rural population was over 2 times higher (5.2 of 1000 vs. 12.4 of 1000) and health expenditures per capita were nearly one third lower (2969 yuan vs. 1056 yuan) in 2012 [13]. Although many factors account for the large gap between urban and rural environments, access to the health care system is a pivotal factor [14]. Equitable utilisation of health care is now a research priority in China [1].

A number of studies have compared the differences between rural and urban residents in the utilization of medical care services. Research has generally found lower utilization of all sorts of health care services in the rural area [1, 1522], due to the unbalanced development between urban and rural areas in medical service supply. Urban–rural health disparities are expected to be even more pronounced in China since the Chinese government enforces a household registration system (hukou) to control internal migration. The hukou system, established in 1955, classified all residents into agricultural (rural) and non-agricultural (urban) registration categories. During the era of planned economy (1956~ 1978), the policy favoured urban hukou holders in many ways such as employment opportunities, ration stamps, housing, and subsidized services. Following China’s economic transition and urbanization in the 1980s, a large number of rural residents moved to cities without converting their hukou status. During period of this study (1993~ 2011), although the government gradually eased the hukou regulations, rural residents still encountered barriers in obtaining basic public services and welfare such as healthcare, education system, and social security coverage [23, 24]. For example, the social health insurance system has been separated into the urban system and rural system by hukou. Urban employees and unemployed residents respectively obtain health insurance through programs called Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI), whereas rural hukou holders are stipulated to participate in a community health insurance scheme known as the New Cooperative Medical System (NCMS) [25, 26]. Compared with the urban insurance, rural health insurance has inferior health coverage and inconvenient reimbursement procedures, which result in potential barriers for rural residents to obtain appropriate and cost-effective health care [27, 28]. Therefore, we estimate urban-rural disparities from the perspective of hukou in this study.

Health care utilization is the most activity-related and consumer-oriented problem in planning health care delivery [21]. The Chinese government conducted an array of reforms aimed at narrowing urban-rural disparities since 1997 [9]. Previous studies, which have been based on a cross-sectional or early period database [2932], may not reflect the longitudinal effects of the reform activities. Given this background, our study seeks to meet three objectives: first, to explore the extent to which rural and urban patients differed in health care utilizing behaviour in view of hukou; second, to determine how much of the variation in health care utilization remains once other determinants are accounted for; and third, to examine trends of urban-rural disparities in health care utilization by capitalizing on a longitudinal database from 1993 to 2011.

Methods

Data

Seven waves of data from the China Health and Nutrition Survey (CHNS) were used to study urban–rural disparities in health care utilization among Chinese Adults from 1993 to 2011. The CHNS is an ongoing project held by University of North Carolina Chapel Hill and the Chinese Centre for Disease Control and Prevention, dating back to1989. Although nine waves of data have been publicly available, the hukou information has been only collected in waves beginning in 1993. Thus, we used CHNS 1993–2011 in this study and focused on adults above the age of 18 who had been sick, or suffered from a chronic or acute disease during the previous 4 weeks.

Framework

We assumed that individuals who reported being sick during the last 4 weeks were faced with four different alternatives including: not seeking care, self-care, outpatient visit, and inpatient visit. Thus, health care utilization was measured as self-care utilization, outpatient utilization, and inpatient utilization, where no care was used as a reference group in the estimation. In particular, self-care (such as taking medication stored at home or purchased at a pharmacy) was considered as one of the major ways to use health care, because a prescription was not required when purchasing drugs at a pharmacy before 2006 in China [29]. Each eligible pharmacy is staffed with 1–2 pharmacists or visiting doctors, who can provide simple consultation and referral services for patients. The drug cost in certificated pharmacies could also be partly covered by individual saving accounts (ISA) of health insurance [33].

The utilization of health services could be viewed as a type of individual behaviour [34]. We used the Andersen/Aday Health Behaviour Model to assess whether hukou bears relation to individuals’ health care utilization [3538]. According to the model, usage of health services is determined by need factors, enabling factors, and predisposing factors. The association we were trying to test can be expressed in the following general equation:
$$ {\mathrm{hcu}}_{\mathrm{i}}=\mathrm{f}\left({\mathrm{hn}}_{\mathrm{i}},{\mathrm{he}}_{\mathrm{i}},{\mathrm{pd}}_{\mathrm{i}},{\mathrm{HUKOU}}_{\mathrm{i}},{\mathrm{wave}}_{\mathrm{i}},{\mathrm{HUKOU}}_{\mathrm{i}}\ast {\mathrm{wave}}_{\mathrm{i}}\right) $$
(1)

Where hn i was a vector of health need characteristics, including categorical variables for illness/injury severity (not severe, somewhat severe, quite severe), a dummy variable indicating whether individuals had been diagnosed having diseases including hypertension, diabetes, myocardial infarction, stroke or transient ischemic attack, cancer, bone fracture, asthma (disease history); he i was a vector of health enabling characteristics, including education (formal education years), income proxy by per capita per year household income in 2011 value, categorical dummy variables for health insurance (NCMS, URBMI, UEBMI; others including commercial medical insurance, government free medical insurance), categorical variables for area (western, central, north-eastern, eastern); pd i was a vector of predisposing characteristics, including a continuous age variable (age), a dummy variable for gender (female), and a binary variable for marital status (married). In particular, as the key explanatory variable, the dichotomous variable HUKOU was singled out, assessed with a question: “To which type of household registration do you belong, urban or rural?” To capture how health care utilization and urban-rural disparities shifted over time, we included categorical variables wave i indicating time periods (1993, 1997, 2000, 2004, 2006, 2009, and 2011) and an interaction term HUKOU i wave i into model (1).

Statistical analyses

We began our analysis by comparing measures of health care utilization as well as other explanatory variables between urban and rural samples, using pooled cross-sectional CHNS data for 1993–2011. χ2 Tests for dichotomous variables and t-tests for continuous variables were used to assess whether the urban–rural differences were statistically significant; we also reported their p-values. Due to the nature of the dependent variable, multinomial logistic (MNL) estimation was employed to study urban-rural disparities of health care utilization after controlling for the confounding variables, and to check their statistical significance level. Relative risk ratios (RRR) and their p-values were also reported. We also test the independence of irrelevant alternatives (IIA) by using Hausman-McFadden test [39] to avoid inconsistent parameter estimates due to non-compliance with IIA.

Results

Descriptive results

According to Table 1, statistically significant differences between rural and urban adults were observed for all the characteristics. Table 1 demonstrated that on average rural adults were slightly younger, with a larger proportion of female to male, and a lower level of education and income. Rural individuals also tended to be married, had less disease history, and large proportion were severely sick. The summary statistic also illustrated that individuals who lived in western and central areas were more inclined to be rural hukou holders, whereas more urban individuals lived in north-eastern and eastern regions. The main difference between urban and rural subjects was that most of the rural subjects joined in NCMS whereas most of the urban subjects participated in UEBMI and URBMI. Furthermore, rural individuals had a larger proportion of uninsured and smaller proportion of other insurances.
Table 1

Descriptive statistics

Variable

All

Rural

Urban

P

What did you do when sick?, n (%)

0.000

 Did not pay any attention

957(9.49)

583(10.75)

374(8.03)

 

 Self-care

2650(26.29)

1141(21.04)

1509(32.40)

 

 Outpatient

5860(58.14)

3398(62.67)

2462(52.87)

 

 Inpatient

612(6.07)

300(5.53)

312(6.70)

 

Health need variables

How severe was the illness or injury?, n (%)

0.000

 Not severe (Ref.)

4118(40.86)

2256(41.61)

1862(39.98)

 

 Somewhat severe

4848(48.10)

2507(46.24)

2341(50.27)

 

 Quite severe

1113(11.04)

659(12.15)

454(9.75)

 

Diseases history, n (%)

0.000

 No (Ref.)

6547(64.96)

3936(72.59)

2611(56.07)

 

 Yes

3532(35.04)

1486(27.41)

2046(43.93)

 

Predisposing variables

Age, mean (SD)

55.61(15.45)

54.35(15.20)

57.07(15.62)

0.000

Gender, n (%)

0.001

 Male (Ref.)

4313(42.79)

2236(41.24)

2077(44.60)

 

 Female

5766(57.21)

3186(58.76)

2580(55.40)

 

Marital status, n (%)

0.001

 Married (Ref.)

8116(80.52)

4433(81.76)

3683(79.09)

 

 Others

1963(19.48)

989(18.24)

974(20.91)

 

Health enabling variables

Education, mean (SD)

6.44(4.62)

4.99(3.93)

8.14(4.79)

0.000

Income (RMB in 2011 value), mean (SD)

10,221.41 (12,190.99)

7098.18 (9421.41)

13,857.69 (13,919.75)

0.000

Types of medical insurance, n (%)

0.000

 None (Ref.)

3810(37.80)

2360(43.53)

1450(31.14)

 

 NCMS

3086(30.62)

2791(51.48)

295(6.33)

 

 URBMI

744(7.38)

55(1.01)

689(14.79)

 

 UEBMI

1156(11.47)

50(0.92)

1106(23.75)

 

 Others

1283(12.73)

166(3.06)

1117(23.99)

 

Area (%)

0.000

 Western (Ref.)

2832(28.10)

1832(33.79)

1000(21.47)

 

 Central

3009(29.85)

1776(32.76)

1233(26.48)

 

 North-eastern

1503(14.91)

792(14.61)

711(15.27)

 

 Eastern

2735(27.14)

1022(18.85)

1713(36.78)

 

Wave, n (%)

0.000

 1993 (Ref.)

343(3.40)

204(3.76)

139(2.98)

 

 1997

656(6.51)

368(6.79)

288(6.18)

 

 2000

695(6.90)

367(6.77)

328(7.04)

 

 2004

1854(18.39)

1085(20.01)

769(16.51)

 

 2006

1551(15.39)

968(17.85)

583(12.52)

 

 2009

2094(20.78)

1190(21.95)

904(19.41)

 

 2011

2886(28.63)

1240(22.87)

1646(35.34)

 

χ2Tests for dichotomous variables and t-tests for continuous variables

It is worth highlighting the distribution of what individuals did when they got sick. Table 1 revealed that the majority of the patients chose outpatient care as their treatment option, with a larger proportion of rural to urban (62.67% vs. 52.87%, P < 0.001). Apart from outpatient, self-care was the most likely choice for sick individuals, with a larger proportion of urban to rural (32.40% vs. 21.04%). Rural residents also tended to choose no care and less likely to choose inpatient care when they got sick compared to their urban counterparts. Approximately 11% of rural adults did not pay attention to their sickness compared with 8% of the urban adults.

Figure 1 showed urban and rural trends in health care utilization from 1993 to 2011. Both rural and urban adults’ utilization in Fig. 1 showed a progressive increase in outpatient care from 1993 to 1997, after which there was a slight decrease until 2004. A gradual increase in self-care could be observed in both rural and urban groups, which was in contrast to that of inpatient care.
Fig. 1

Healthcare utilization among urban and rural adults in China (1993–2011)

The greatest difference between urban and rural groups was found in self-care utilization. The raw urban-rural gap in self-care and outpatient care persisted during this period, which indicated different treatment preferences when the disease was not very severe.

Apparently, rural adults became progressively more likely to pay attention when they got sick after 2004, such as being more likely to choose inpatient care. The urban-rural disparities in no care and inpatient care also declined since the year 2004.

Multivariate regression analyses

Table 2 reported the results of multinomial logistic regression for urban-rural disparities in health care utilization. No care was chosen to be the reference category. The Hausman test results in Table 3 showed that none of the four options would reject the IIA assumption.
Table 2

Multinomial logistic regression of Chinese adults’ health care utilisation using pooled CHNS data 1993–2011

 

Self-care

Outpatient

Inpatient

RRR

RRR

RRR

HUKOU: Urban

3.240**

2.234*

4.768***

(1.671)

(0.942)

(2.557)

Wave: 1997

3.720***

3.193***

1.494

(1.473)

(0.982)

(0.679)

Wave: 2000

2.574**

2.053***

1.045

(0.962)

(0.572)

(0.451)

Wave: 2004

2.772***

0.913

0.275***

(0.891)

(0.211)

(0.103)

Wave: 2006

2.826***

1.142

0.339***

(0.934)

(0.276)

(0.133)

Wave: 2009

3.822***

1.390

0.583

(1.318)

(0.359)

(0.240)

Wave: 2011

4.102***

1.394

0.896

(1.428)

(0.365)

(0.367)

Urban*1997

0.826

0.540

0.545

(0.553)

(0.315)

(0.394)

Urban*2000

0.789

0.553

0.206**

(0.479)

(0.282)

(0.142)

Urban*2004

0.589

0.489#

0.270**

(0.314)

(0.216)

(0.162)

Urban*2006

0.846

0.666

0.507

(0.468)

(0.308)

(0.315)

Urban*2009

0.347*

0.262***

0.145***

(0.189)

(0.119)

(0.087)

Urban*2011

0.333**

0.355**

0.096***

(0.183)

(0.162)

(0.058)

Health need factors

How severe was the illness or injury: Somewhat severe

1.417***

2.351***

5.715***

(0.115)

(0.177)

(0.837)

How severe was the illness or injury: Quite severe

1.920***

4.411***

46.940***

(0.349)

(0.746)

(9.877)

Diseases history: Yes

1.213**

1.371***

1.636***

(0.113)

(0.119)

(0.206)

Predisposing factors

Age

0.995#

0.995#

1.002

(0.003)

(0.003)

(0.005)

Gender: male

0.974

1.032

0.825*

(0.080)

(0.079)

(0.095)

Marital status: married

0.831*

0.727***

0.800#

(0.079)

(0.064)

(0.113)

Health enabling factors

Education

1.030**

1.010

1.002

(0.012)

(0.011)

(0.016)

Household income per capita

1.000

1.000

1.000

(0.000)

(0.000)

(0.000)

Types of medical insurance: NCMS

1.090

1.254*

1.462*

(0.144)

(0.150)

(0.312)

Types of medical insurance: URBMI

1.301

1.579**

2.556***

(0.277)

(0.313)

(0.793)

Types of medical insurance: UEBMI

1.652**

1.297

3.432***

(0.324)

(0.239)

(0.993)

Types of medical insurance: others

1.384**

1.275*

2.241***

(0.216)

(0.187)

(0.486)

Province: Central

0.762***

1.013

1.185

(0.078)

(0.096)

(0.171)

Province: North-eastern

1.158

0.569***

0.690**

(0.136)

(0.064)

(0.127)

Province: Eastern

0.707***

1.112

0.877

(0.0815)

(0.117)

(0.144)

Constant

0.611

3.056***

0.129***

(0.216)

(0.840)

(0.0558)

Observations

10,079

10,079

10,079

R-squared

0.081

Robust standard errors are reported in parenthesis; *** p < 0.01, ** p < 0.05, * p < 0.1, # p < 0.15

Table 3

Hausman test results of the IIA

Omitted

chi2

df

P > chi2

evidence

0

− 4500.000

28

1.000

for Ho

1

− 4000.000

54

1.000

for Ho

2

−51.937

56

1.000

for Ho

3

− 510.629

28

1.000

for Ho

The urban-rural disparity was particularly evident in inpatient care utilization, after controlling for the confounding variables in eq. (1). The likelihood of choosing inpatient care vs. no care was 4.77 times greater for urban adults relative to rural adults when they got ill, which was statistically significant at the 1% level. Also, urban adults were 3.24 times more likely than their rural counterparts to choose self-care vs. no care (RRR = 3.240; p < 0.05) and were 2.23 times more likely to choose outpatient care vs. no care (RRR = 2.234; p < 0.1) when the confounding variables were held constant.

Results of health care utilization trends suggested a significant upward trend of self-care utilization, though there was a slight decrease in the 1997–2000 period. Compared to no care, after a sharp upward trend from 1993 to 1997, patients were less likely to use outpatient care from 1997 to 2004, and more likely to use outpatient care from 2004 to 2011. After the above-mentioned changes in trend, the probability of outpatient care vs. no care in 2011 was 1.394 times that of 1993. Similar trends could be discovered in inpatient care utilization. More specifically, the probability of inpatient care vs. no care in 2011 was even less than that of 1993.

Changes in urban-rural disparities could be clarified by the interaction between hukou dummy and wave dummies in Table 2. Decline trends of urban-rural disparities could be observed in self-care, outpatient care, and inpatient care from 1993 to 2011, though there was an increase from 2004 to 2006. More specifically, the downward trend of urban-rural disparities was the most obvious in inpatient care utilization, which was significant in most of the survey years. The hukou distinctions in self-care, outpatient care, and inpatient care in 2011 were only 33.3%, 35.5%, and 9.6% that of 1993, respectively.

Consistent with these findings, visible health care utilization disparities could be observed among different insurance types. The UEBMI participants were most likely to use self-care and inpatient care, while the URBMI participants were most likely to use outpatient care. In sum, the urban insurance enrolees had a higher likelihood of using health care than rural insurance enrolees.

Moreover, the severity of illness or injury and disease history had positive effects on all types of health care utilization, while age and marital status had negative effect on health care utilization. Adults with better education had a higher probability to choose self-care rather than no care.

Discussion

The present study showed that more than half of patients chose outpatient care as their treatment option when they felt sick during the 4 weeks before the survey. However, although an insignificant increase in outpatient care utilization could be observed from 2004 to 2011 when holding everything else constant, the probability of choosing outpatient care was much lower than that before 2000. Instead, patients were more likely to use self-care since 2000. The most straightforward explanation for this phenomenon would be the sharp rise in health service costs. Between 1995 and 2011, average per capita health expenditures increased from 110.1 to 969.0 yuan among urban residents, and from 42.5 to 436.8 yuan among rural residents [13]. Some urban and many rural residents who could not afford such medical expenditures had to buy drugs from pharmacies [40], even for serious diseases like HIV/AIDS [41]. Additionally, the Chinese government has implemented the drug sales network in recent years, which highly improved the accessibility of pharmacies and medicines [40]. Some studies found that the aging population might be responsible for the increasing self-care utilization because seniors relied more on self-care to save the economic and time cost involved in seeking professional health care [42]. In developing countries, where heath service resources are scarce, despite being associated with risks [43], self-care should be an important supplemental approach to professional medical facilities. As the role of pharmacies in health care has been recognized by many countries [4345], those pharmacies in China should take more responsibility for self-care monitoring and management.

We also concluded that rural hukou holders used less health care than their urban counterparts. Moreover, the hukou distinction in inpatient care utilization was more obvious than the distinctions in self-care and inpatient care utilization. These findings were consistent with earlier studies about urban-rural gaps in health care utilization [9, 29, 46, 47]. More specifically, rural residents had a higher proportion of outpatient care than urban residents in the descriptive results but had a lower probability of using outpatient care in the multivariate results after controlling for the confounding variables. The opposite results demonstrated that the urban-rural disparities on health care utilization were even more obvious than observed.

There are several potential explanations for the urban-rural disparities observed in this study. First, consistent with most previous studies from other countries, people in rural areas usually have a shortage of health care providers, extended travel, low socioeconomic status, and lack social support [1, 3, 4851] [16]. Registered doctors per thousand populations in urban communities were 2.57 times more than in rural communities in China [13]. The second explanation is the different welfare system between urban and rural, due hukou. The major welfare benefit associated hukou is the social benefits system including health insurance [23, 52, 53]. The rural hukou holders are stipulated to participate in the local NCMS, which has lower benefit than that of the UEBMI and URBMI in urban areas. In 2008, the actual co-payment rates of UEBMI, URBMI, and NCMS were 36.8%, 50.7%, and 73.4%, respectively [54]. Under the two-class health insurance system, rural residents usually encounter more financial barriers in health care utilization. The average hospitalization expenses of the NCMS enrolees account for 56% of per capita annual income in 2008, while the proportions for UEBMI and URBMI enrolees are only 31.8% and 38.2%, respectively [54]. Such heavy burden compels rural patients to stay away from inpatient care, which can also explain why we could observe a larger urban-rural gap in inpatient care use than self-care and outpatient care use. Our findings suggested that extending health insurance coverage may have limited effect on promoting urban-rural equity, and integrating the decentralized insurance system into one uniform system should be taken into consideration. Moreover, the lack of inpatient health services provision in rural areas and the consequent long distance to gain access to appropriate treatment may also function as significant obstacles for rural residents to access and use inpatient health care.

An encouraging finding was that the urban-rural disparities in health care utilization had narrowed from 1993 to 2011, though not significantly before 2009. The continuous coverage expansion and benefit improvement of rural health insurance might have played a positive role in the gap narrowing. Between 1993 to 2013, the rural insurance coverage extended from 15.9% to 97.3% [54]. Besides, The central and local government subsidy increased from minimum 20 yuan in 2003 to 80 yuan in 2008, and to minimum 120 yuan in 2010 per enrolee per year [54]. Recently, immediate reimbursement from NCMS has been realized in more and more rural areas, which means NCMS enrolees only need to pay out-of-pocket for part of their medical expenditure [55]. All these reasons might work together to lower the financial barrier and to promote equal use of health care. More specifically, obvious decrements could be observed in self-care, outpatient care, and inpatient care since 2009, which might be due to the new nationwide health care system reform in China. In 2009, the central government of China started new health care reforms, which targeted universal and equitable access to health care by 2020 [46, 56]. Between 2009 and 2011, 850 billion yuan had been spent in expanding health insurance coverage, improving primary care, establishing essential medicines system, promoting public health services, and piloting public hospital reform [56, 57]. All the initiatives mentioned above might have contributed to the decrements. Moreover, the decline in inpatient care utilization was more obvious than the changes in self-care and outpatient care use, which could be associated with the NCMS reimbursement policies that focus on inpatient coverage [46]. Considering that primary care is more affordable and efficient in reducing health disparities [58], greater attention should be given to covering the costs of primary care through NCMS, such as the coverage of chronic disease management and treatment.

Our findings on trends in urban-rural disparities were consistent with Meng et al. [46]. However, earlier research conducted by Liu et al. and Gao et al. showed widening gaps in health care utilization between urban and rural from 1980s to 1993 and from 1993 to 1998, respectively [47] [59], which was opposite to our multivariate findings. There are several possible explanations for the discrepancy between their studies and our findings. First, Liu et al. and Gao et al. used secondary data sources without adjusting for confounders. Our results on trends of the raw urban-rural gaps had similar differences from the trends after controlling confounding variables. Second, Liu et al. and Gao et al. used living location to distinguish between urban and rural, while we defined urban and rural residents by hukou. During the past few decades, large-scale young people moved into cities leaving the elderly behind in the countryside, which might result in a more rapidly aging trend in rural areas compared to urban areas [12]. Most of these rural-to-urban migrants still held rural hukou and would not affect our results.

In addition, our findings suggested that the pattern of health seeking behaviours were different among different areas. For example, patients in central and eastern regions were less likely to use self-care and were more likely to use outpatient care, while patients in the north-eastern region were more intent on using self-care and were less likely to use professional health service. This reflected the uneven distribution of health resources among different parts of China [58]. Correspondingly, different policy interventions should be implemented to improve health care utilization accordingly. The government should improve the health infrastructure in undeveloped regions to encourage people to use health services when needed. For the eastern region, improving the primary care to disperse crowds of patients at big hospitals need further efforts.

Limitations

The results from the present study should be interpreted with caution as there are some limitations. First, our data source did not include information on physician/provider practice style and the environmental factors related to health care utilization, which might be important in explaining rural–urban differences. Variation in provider side effects is an important area for further study. Second, health-related data including self-reported health status and some objective indicators were no longer available from CHNS since 2009, making it difficult to take the urban-rural health difference into consideration. Third, we did not assess quality and quantity of health care, or access to other sectors of the health care system, such as preventive services. Thus, an expanded study that examines disparities not only in health seeking behaviours but also in quantity and quality of health care usage needs to be conducted.

Conclusion

Despite these limitations, this study is among the first to investigate the urban-rural disparities in health care seeking behaviours associated with hukou. Also, we used a longitudinal individual-level database including the most recent data, which explored some up-to-date findings on trends in urban-rural disparities. The present study showed that rural residents were still underutilizing health care when compared to their urban counterparts, and institutional differences between urban and rural in health care utilization were more notable than observed from statistical data. Fortunately, the Chinese government abolished the urban and rural hukou distinction in October 2014. Our findings attest to the wisdom of this abolishment. Although the urban-rural disparities have declined between 1993 and 2011, policy makers still need to be aware of the challenges due to aging problems and health expenditure increases. Therefore, a comprehensive approach to achieving and maintaining equity in health and heath care utilization may focus on: integrating the decentralized insurance system into one uniform system, providing more primary care services covered by health insurance, and equitable and reasonable allocation of health resources between urban and rural areas.

Abbreviations

CHNS: 

China Health and Nutrition Survey

ISA: 

Individual saving accounts

MNL: 

multinomial logistic

NCMS: 

New cooperative medical system in rural

RRR: 

Relative risk ratios

UEBMI: 

Urban employee basic medical insurance

URBMI: 

Urban resident basic medical insurance

Declarations

Acknowledgements

This research uses data from China Health and Nutrition Survey (CHNS). We thank the National Institute for Nutrition and Health, China Center for Disease Control and Prevention, Carolina Population Center, the University of North Carolina at Chapel Hill for supplying the CHNS data from 1989 to 2015.

Funding

This study was supported by the National Natural Science Foundation of China (71303137 & 71673170).

Availability of data and materials

The datasets supporting the conclusions of this article are publicly available in the CHNS website [http://www.cpc.unc.edu/projects/china].

Authors’ contributions

JL conceptualized this study, performed the statistical analysis and drafted the manuscript. LS participated to data analysis and helped to revise the draft. HL participated to study design and helped to revise the draft. GD participated in the study and contributed to drafting background section of the manuscript. LX participated in the design and implementation. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
School of Public Health Shandong University, Jinan, People’s Republic of China
(2)
Johns Hopkins Bloomberg School of Public Health, Baltimore, USA

References

  1. Haggerty JL, Roberge D, Levesque JF, Gauthier J, Loignon C. An exploration of rural-urban differences in healthcare-seeking trajectories: implications for measures of accessibility. Health Place. 2014;28:92–8.View ArticlePubMedGoogle Scholar
  2. Chen Y, Yin Z, Xie Q. Suggestions to ameliorate the inequity in urban/rural allocation of healthcare resources in China. Int J Equity Health. 2014;13:34.View ArticlePubMedPubMed CentralGoogle Scholar
  3. Shi LY. Health-care in China - a rural-Urban comparison after the socioeconomic reforms. Bull World Health Organ. 1993;71(6):723–36.PubMedPubMed CentralGoogle Scholar
  4. Fang H, Chen J, Rizzo JA. Explaining urban-rural health disparities in China. Med Care. 2009;47(12):1209–16.View ArticlePubMedGoogle Scholar
  5. Liu H, Fang H, Zhao Z. Urban-rural disparities of child health and nutritional status in China from 1989 to 2006. Econ Hum Biol. 2013;11(3):294–309.View ArticlePubMedGoogle Scholar
  6. Tian D, Sun L, Zhang L, Zhang L, Zhang W, Li L, Deng X, Ning P, Cheng X, Deng J, et al. Large urban-rural disparity in the severity of two-week illness: updated results based on the first health service survey of Hunan Province, China. Int J Equity Health. 2016;15:37.View ArticlePubMedPubMed CentralGoogle Scholar
  7. Fei X, Wu J, Kong Z, Christakos G. Urban-rural disparity of breast cancer and socioeconomic risk factors in China. PLoS One. 2015;10(2):e0117572.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Hou XH. Urban-rural disparity of overweight, hypertension, undiagnosed hypertension, and untreated hypertension in China. Asia Pac J Public Health. 2008;20(2):159–69.View ArticleGoogle Scholar
  9. Jian W, Chan KY, Reidpath DD, Xu L. China's rural-Urban Care gap shrank for chronic disease patients, but inequities persist. Health Aff. 2010;29(12):2189–96.View ArticleGoogle Scholar
  10. Li LW, Liu JY, Xu HW, Zhang ZM. Understanding rural-urban differences in depressive symptoms among older adults in China. J Aging Health. 2016;28(2):341–62.View ArticlePubMedGoogle Scholar
  11. Zhai SD, McGarvey ST. Temporal changes and rural-Urban differences in cardiovascular-disease risk-factors and mortality in China. Hum Biol. 1992;64(6):807–19.PubMedGoogle Scholar
  12. Wang S, Kou C, Liu Y, Li B, Tao Y, D'Arcy C, Shi J, Wu Y, Liu J, Zhu Y, et al. Rural-urban differences in the prevalence of chronic disease in northeast China. Asia Pac J Public Health. 2015;27(4):394–406.View ArticlePubMedGoogle Scholar
  13. China NHaFPCo. Health and family planning statistics yearbook (2015). Beijing: China Union Medical University Press; 2015.Google Scholar
  14. Zimmer Z, Kwong J. Socioeconomic status and health among older adults in rural and urban China. J Aging Health. 2004;16(1):44–70.View ArticlePubMedGoogle Scholar
  15. Alexandre PK, Saint-Jean G, Crandall L, Fevrin E. Prenatal care utilization in rural areas and urban areas of Haiti. Rev Panam Salud Publica. 2005;18(2):84–92.View ArticlePubMedGoogle Scholar
  16. De la Cruz-Sanchez E, Aguirre-Gomez L. Health related lifestyle and preventive medical care of rural Spanish women compared to their urban counterparts. J Immigr Minor Health. 2014;16(4):712–8.PubMedGoogle Scholar
  17. Fadum EA, Stanley B, Rossow I, Mork E, Tormoen AJ, Mehlum L. Use of health services following self-harm in urban versus suburban and rural areas: a national cross-sectional study. BMJ Open. 2013;3(7):e002570.Google Scholar
  18. Farmer J, Iversen L, Campbell NC, Guest C, Chesson R, Deans G, MacDonald J. Rural/urban differences in accounts of patients’ initial decisions to consult primary care. Health Place. 2006;12(2):210–21.View ArticlePubMedGoogle Scholar
  19. Kamal N, Curtis S, Hasan MS, Jamil K. Trends in equity in use of maternal health services in urban and rural Bangladesh. Int J Equity Health. 2016;15:27.View ArticlePubMedPubMed CentralGoogle Scholar
  20. Koller D, Eisele M, Kaduszkiewicz H, Schön G, Steinmann S, Wiese B, Glaeske G, van den Bussche H. Ambulatory health services utilization in patients with dementia – is there an urban-rural difference? Int J Health Geogr. 2010;9:59.View ArticlePubMedPubMed CentralGoogle Scholar
  21. Oladipo JA. Utilization of health care services in rural and urban areas: a determinant factor in planning and managing health care delivery systems. Afr Health Sci. 2014;14(2):322–33.View ArticlePubMedPubMed CentralGoogle Scholar
  22. Zhang P, Tao G, Irwin KL. Utilization of preventive medical services in the United States: a comparison between rural and urban populations. J Rural Health. 2000;16(4):349–56.View ArticlePubMedGoogle Scholar
  23. Song Y. What should economists know about the current Chinese hukou system? China Econ Rev. 2014;29:200–12.View ArticleGoogle Scholar
  24. Treiman DJ. The “difference between heaven and earth”: urban-rural disparities in well-being in China. Res Soc Stratif Mobil. 2012;30(1):33–47.View ArticleGoogle Scholar
  25. Liu J, Shi L, Meng Q, Khan MM. Income-related inequality in health insurance coverage: analysis of China health and nutrition survey of 2006 and 2009. Int J Equity Health. 2012;11:42.View ArticlePubMedPubMed CentralGoogle Scholar
  26. Lei X, Lin W. The new cooperative medical scheme in rural China: does more coverage mean more service and better health? Health Econ. 2009;18(Suppl 2):S25–46.View ArticlePubMedGoogle Scholar
  27. Liu H, Rizzo JA, Fang H. Urban-rural disparities in child nutrition-related health outcomes in China: the role of hukou policy. BMC Public Health. 2015;15:1159.View ArticlePubMedPubMed CentralGoogle Scholar
  28. Zhu H. Unmet needs in long-term care and their associated factors among the oldest old in China. BMC Geriatr. 2015;15:46.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Liu M, Zhang Q, Lu M, Kwon C-S, Quan H. Rural and urban disparity in health services utilization in China. Med Care. 2007;45(8):767–74.View ArticlePubMedGoogle Scholar
  30. Akin JS, Dow WH, Lance PM, Loh CPA. Changes in access to health care in China, 1989-1997. Health Policy Plan. 2005;20(2):80–9.View ArticlePubMedGoogle Scholar
  31. Henderson GE, Akin JS, Hutchinson PM, Jin SG, Wang JM, Dietrich J, Mao LM. Trends in health services utilization in eight provinces in China, 1989-1993. Soc Sci Med. 1998;47(12):1957–71.View ArticlePubMedGoogle Scholar
  32. Liu X, Li NX, Liu CJ, Ren XH, Liu DP, Gao B, Liu YY. Urban-rural disparity in utilization of preventive care services in China. Medicine. 2016;95(37):e4783.Google Scholar
  33. Li X, Zhang W. The impacts of health insurance on health care utilization among the older people in China. Soc Sci Med. 2013;85:59–65.View ArticlePubMedGoogle Scholar
  34. Andersen R, Newman JF. Societal and individual determinants of medical care utilization in United-States. Milbank Mem Fund Q Health Soc. 1973;51(1):95–124.View ArticlePubMedGoogle Scholar
  35. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974;9(3):208–20.PubMedPubMed CentralGoogle Scholar
  36. Aday LA, Andersen RM. Equity of access to medical-care - a conceptual and empirical overview. Med Care. 1981;19(12):4–27.View ArticleGoogle Scholar
  37. Andersen R, Aday LA. Access to medical-care in United-States - realized and potential. Med Care. 1978;16(7):533–46.View ArticlePubMedGoogle Scholar
  38. Andersen RM, McCutcheon A, Aday LA, Chiu GY, Bell R. Exploring dimensions of access to medical-care. Health Serv Res. 1983;18(1):49–74.PubMedPubMed CentralGoogle Scholar
  39. Hausman J, McFadden D. Specification tests for the multinomial Logit model. Econometrica. 1984;52(5):1219–40.View ArticleGoogle Scholar
  40. Li YF, Rao KQ, Ren XW. Use of and factors associated with self-treatment in China. BMC Public Health. 2012;12:995.View ArticleGoogle Scholar
  41. Lieber E, Li L, Wu ZY, Rotheram-Borus MJ, Guan JH, HIV NC. HIV/STD stigmatization fears as health-seeking barriers in China. AIDS Behav. 2006;10(5):463–71.View ArticlePubMedPubMed CentralGoogle Scholar
  42. XP Z. Self-medication's development and developing new dosage form of OTC drugs of digestive system. Food Drug. 2006;8(7):17–9.Google Scholar
  43. Wen Y, Lieber E, Wan D, Hong YH, Prevent NCHS. A qualitative study about self-medication in the community among market vendors in Fuzhou, China. Health Soc Care Community. 2011;19(5):504–13.View ArticlePubMedGoogle Scholar
  44. Noyce PR. Providing patient care through community pharmacies in the UK: policy, practice, and research. Ann Pharmacother. 2007;41(5):861–8.View ArticlePubMedGoogle Scholar
  45. Thanh NX, Lofgren C, Ho Dang P, Nguyen Thi Kim C, Lindholm L. An assessment of the implementation of the health care funds for the poor policy in rural Vietnam. Health Policy. 2010;98(1):58–64.View ArticlePubMedGoogle Scholar
  46. Meng Q, Xu L, Zhang YG, Qian JC, Cai M, Xin Y, Gao J, Xu K, Boerma JT, Barber SL. Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study. Lancet. 2012;379(9818):805–14.View ArticlePubMedGoogle Scholar
  47. Liu YL, Hsiao WC, Eggleston K. Equity in health and health care: the Chinese experience. Soc Sci Med. 1999;49(10):1349–56.View ArticlePubMedGoogle Scholar
  48. Zhang WQ, Mueller KJ, Chen LW. Uninsured hospitalizations: rural and urban differences. J Rural Health. 2008;24(2):194–202.View ArticlePubMedGoogle Scholar
  49. Weaver KE, Geiger AM, Lu L, Case LD. Rural-urban disparities in health status among US cancer survivors. Cancer. 2013;119(5):1050–7.View ArticlePubMedGoogle Scholar
  50. Kroneman M, Verheij R, Tacken M, van der Zee J. Urban-rural health differences: primary care data and self reported data render different results. Health Place. 2010;16(5):893–902.View ArticlePubMedGoogle Scholar
  51. Sibley LM, Weiner JP. An evaluation of access to health care services along the rural-urban continuum in Canada. BMC Health Serv Res. 2011;11:20.View ArticlePubMedPubMed CentralGoogle Scholar
  52. Afridi F, Li SX, Ren Y. Social identity and inequality: the impact of China's hukou system. J Public Econ. 2015;123:17–29.View ArticleGoogle Scholar
  53. Liu ZQ. Institution and inequality: the hukou system in China. J Comp Econ. 2005;33(1):133–57.View ArticleGoogle Scholar
  54. NHFPC CfHSaIo. An analysis report of the fifth National Health Services Survey in China. Beijing: China Union Medical University Press; 2013.Google Scholar
  55. Zhang L, Wang ZH, Qian DF, Ni J. Effects of changes in health insurance reimbursement level on outpatient service utilization of rural diabetics: evidence from Jiangsu Province, China. BMC Health Serv Res. 2014;14:185.View ArticlePubMedPubMed CentralGoogle Scholar
  56. Yang Q, Dong H. Have health human resources become more equal between rural and urban areas after the new reform? Int J Health Policy Manag. 2014;3(7):359–60.View ArticlePubMedPubMed CentralGoogle Scholar
  57. Hou Z, Meng Q, Zhang Y. Hypertension prevalence, awareness, treatment, and control following China's healthcare reform. Am J Hypertens. 2016;29(4):428–31.View ArticlePubMedGoogle Scholar
  58. Fang PQ, Dong SP, Xiao JJ, Liu CJ, Feng XW, Wang YP. Regional inequality in health and its determinants: evidence from China. Health Policy. 2010;94(1):14–25.View ArticlePubMedGoogle Scholar
  59. Gao J, Qian JC, Tang SL, Eriksson B, Blas E. Health equity in transition from planned to market economy in China. Health Policy Plan. 2002;17:20–9.View ArticlePubMedGoogle Scholar

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© The Author(s). 2018

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