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Rural and Urban Disparity in Health Services Utilization in China

Liu, Meina MD, PhD*; Zhang, Qiuju MD, MPH*; Lu, Mingshan PhD†¶; Kwon, Churl-Su MD§; Quan, Hude MD, PhD‡∥

doi: 10.1097/MLR.0b013e3180618b9a
Original Article

Objectives: To describe patterns in physician and hospital utilization among rural and urban populations in China and to determine factors associated with any differences.

Methods: In 2003, the Third National Health Services Survey in China was conducted to collect information about health services utilization from randomly selected residents. Of the 193,689 respondents to the survey (response rate, 77.8%), 6429 urban and 16,044 rural respondents who were age 18 or older and reported an illness within the last 2 weeks before the survey were analyzed. Generalized estimating equations with a log link were used to assess the relationship between rural/urban residence and physician visit/hospitalization to adjust for respondents clustered at the household level.

Results: About half of respondents did not see a physician when they were ill. Rural respondents used physicians more than urban respondents (52.0% vs. 43.0%, P < 0.001) and used hospitals less (7.6% vs. 11.1%, P < 0.001). Factor associated with increased physician utilization included residing in rural areas among majority Chinese (ie, Han) [rate ratio (RR), 1.21; 95% confidence interval (95% CI), 1.16–1.26], residing <3 km away from the medical center (RR, 1.16; 95% CI, 1.12–1.21), or being uninsured (RR, 1.38; 95% CI, 1.30–1.46). Rural minority Chinese visited physicians significantly less than urban minority Chinese (RR, 0.90; 95% CI, 0.83–0.98). Hospital utilization was significantly lower among rural males (RR, 0.84; 95% CI, 0.72–0.98), rural seniors (age, ≥65; RR, 0.64; 95% CI, 0.53–0.77), rural respondents with low education (RR, 0.70; 95% CI, 0.57–0.86 for illiterate), or rural insured respondents (RR, 0.86; 95% CI, 0.69–0.99) than hospitalization among urban counterparts.

Conclusions: Three national approaches should be considered in reforming the healthcare system in China: universal insurance coverage, higher amounts of insurance coverage, and increasing the population's level of education. In addition, access issues in remote areas and by rural minority Chinese population should be addressed.

From the *Department of Biostatistics, School of Public Health, Harbin Medical University, Harbin, China; Departments of †Economics, ‡Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; §Lister Hospital, Corey's Mill Lane, Stevenage, Hertfordshire, United Kingdom; ¶Research Institute of Economics and Management, Southwestern University of Finance and Economics, Chengdu, China; and ∥Centre for Health and Policy Studies, University of Calgary, Calgary, Alberta, Canada.

Supported by a Population Health Investigator Award from the Alberta Heritage Foundation for Medical Research, and by a New Investigator Award from the Canadian Institutes of Health Research, Canada (to H.Q.), and Institute of Health Economics, Alberta (to M.L.).

Reprints: Dr. Hude Quan, Department of Community Health Sciences, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, Canada T2N 4N1. E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.