Ten years of progress towards universal health coverage: has China achieved equitable healthcare financing?

Introduction This study aims to systematically evaluate vertical and horizontal equity in the Chinese healthcare financing system over the period 2008-2018 during the progress towards Universal Health Coverage (UHC), and to examine how both types of equity have changed during this period. Methods Household information on healthcare payments was collected from 2398 households involving 7021 individuals in 2008, 3600 households involving 10 466 individuals in 2013 and 3660 households involving 11 550 individuals in 2018. Redistributive effects of healthcare financing system were decomposed into progressivity, pure horizontal inequity and reranking. Progressivity analysis and the Aronson-Johnson-Lambert decomposition method were adopted to measure the vertical equity and horizontal equity of healthcare financing. Results Over the period 2008-2018, healthcare financing through indirect taxes showed a slightly prorich structure and healthcare financing through direct taxes showed a propoor structure in both urban and rural areas. Urban Employee Basic Medical Insurance experienced redistribution from the poor to the rich during the period 2008-2013, but then experienced redistribution from the rich to the poor during the period 2013-2018. Urban Resident Basic Medical Insurance (URBMI), New Rural Cooperative Medical Scheme (NRCMS), Urban and Rural Resident Basic Medical Insurance (URRBMI) and out-of-pocket payments experienced redistribution from the poor to the rich over the entire period. Conclusion China's healthcare financing has experienced redistribution from the poor to the rich during 10 years of progress toward the UHC. UHC improved access to and utilisation of healthcare in urban areas. The flat rate contribution mechanism should be renovated for URBMI, NRCMS and URRBMI.