Abstract
BACKGROUND: Healthcare inequities pose a substantial challenge to achieving universal health coverage, particularly in low- and middle-income countries (LMICs). The Chinese government implemented Hierarchical Medical System (HMS) to optimize resource allocation and improve healthcare access. This study aimed to evaluate the impact of HMS on healthcare utilization and the inequities. METHODS: This study utilized longitudinal data from the China Family Panel Studies (CFPS) conducted in 2012, 2014, 2016, and 2018, which included a final sample of 105,335 individuals. A multiple-period difference-in-differences method was employed to explore the impact on outpatient and inpatient utilization across socioeconomic dimensions. The concentration Index and the horizontal inequity index (HI) were used to assess inequities in healthcare utilization. Additionally, a decomposition analysis was performed to identify the contributors to inequalities. RESULTS: HMS demonstrated significant negative impacts on both outpatient and inpatient utilization (OR = 0.825, SE = 0.058; OR = 0.869, SE = 0.071, respectively), with a short-term decline in outpatient services and a lasting reduction in inpatient services. The heterogeneity tests revealed a pronounced impact in central and rural areas. The results indicated pro-poor inequities in outpatient utilization and pro-rich inequities in inpatient utilization. HMS reduced inequalities and inequities in healthcare utilization, particularly for outpatient services. HI in inpatient services increased in the initial year but decreased after 2 years of HMS. The decomposition analyses identified the primary contributors as economic level and health status. While the economic level exacerbated inequalities, health insurance and higher educational attainment mitigated inequalities in healthcare utilization. CONCLUSION: HMS had an unintended impact on decreasing healthcare utilization in China. HMS improved equity in outpatient utilization, it faced challenges in enhancing equity in inpatient utilization. Policymakers should prioritize strengthening primary care infrastructure in central and rural areas, ensuring affordable healthcare models, reinforcing educational attainment, and expanding health insurance coverage to promote equity in healthcare utilization. These findings provide crucial insights for guiding equitable healthcare reform in LMICs and advancing progress toward the Sustainable Development Goals.