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Background: The accessibility and fairness of the floating population's access to basic public health services have an important impact on improving the health level of the whole population. Existing studies have shown that medical insurance and social integration have an impact on basic public health services, but there are few studies on the specific influence path between the three. Therefore, the research purpose of this paper is to explore the effects of medical insurance for urban and rural residents and basic medical insurance for urban employees on the utilization of basic public health services, and to analyze the mediating effect of social integration. Methods: The data in this paper are derived from the 2017 China Mobile Population Dynamic Monitoring Survey data, which collects information on 31 provinces (regions, cities) and Xinjiang Production and Construction Corps mobile population 169,989 people, all of whom come from China's relatively concentrated mobile population inflow areas (NHC FPSCo. 2021. Floating Population Service Center of NHC). After deleting part of the missing data and replacing the mean value, 154,586 people were finally included in the analysis. The proportion is 90.9%. Based on the data of China's floating population dynamic survey in 2017,we used Logistic regression method to analyze the effects of basic medical insurance for urban and rural residents, basic medical insurance for urban employees and social integration on the utilization of basic public health services. Then we used the Bootstrap method of structural equation model to analyze the mediating effect of social integration. Results: Medical insurance for urban and rural residents (β = 0.236;95%CI:1.195 ~ 1.342) has positive impact on health education, it (β = 0,190;95%CI:1.150 ~ 1.272) also has positive impact on the establishment of residents' health records. Social integration (including political participation (β = 0.312;95%CI:1.324 ~ 1.410),activity participation (β = 0.724;95%CI:2.009 ~ 2.119), identity (β = 0.421; 95%CI:1.387 ~ 1.675))has positive impact on health education, it ((β = 0.312;95%CI:1.324 ~ 1.410), (β = 0.404;95%CI:1.463 ~ 1.534), (β = 0.282;95%CI:1.191 ~ 1.477)) also has positive impact on the establishment of residents' health records. In addition, BMIUE (β = 0.169;95%CI:1.150 ~ 1.219) has an impact on the establishment of residents' health records. The direct effect of medical insurance on the utilization of public health services was 0.092 (95%CI: 0.093 ~ 0.103), social integration was a partial mediator, the mediating effect was 0.127 (95%CI: 0.108 ~ 0.127), and the mediating effect size was 57.73%. Conclusions: Medical insurance can directly promote the floating population to use basic public health services, and can indirectly promote the improvement of public health service utilization level through social integration. [ABSTRACT FROM AUTHOR]

Background: Most existing research on rural–urban health inequalities focuses on disparities in service access and health outcomes based on region. This paper examines rural–urban disparities in maternal healthcare utilization and delivery modes based on household registration (hukou) status to understand the role of state institutions in producing healthcare disparities in China. Methods: Utilizing administrative data from the Public Maternal Health Insurance scheme, we analyzed 54,733 live births in City A (2015–2019) and 25,849 live births in City B (2018–2019) in Guangdong Province in China. We constructed regression models using hukou status (rural versus urban) as the explanatory variable. Results: While there is no statistically significant difference in rural and urban mothers' probability of obtaining the minimum recommended number of prenatal care checkups in City A (OR = 0.990 [0.950, 1.032]), mothers with rural hukou status have a lower probability of obtaining the minimum recommended number of visits in City B than their counterparts with urban hukou (OR = 0.781 [0.740, 0.825]). The probability of delivering in tertiary hospital is lower among mothers with rural hukou than among those with urban hukou in both cities (City A: OR = 0.734 [0.701, 0.769]; City B: OR = 0.336 [0.319, 0.354]). Mothers with rural hukou are more likely to have a Cesarean section than those with urban hukou in both cities (City A: OR = 1.065 [1.027, 1.104]; City B: OR = 1.127 [1.069, 1.189]). Compared with mothers with urban hukou, mothers with rural hukou incurred 4 % (95 % CI [-0.046, -0.033]) and 9.4 % (95 % CI [-0.120, -0.068]) less in total medical costs for those who delivered via Cesarean section and 7.8 % (95 % CI [-0.085, -0.071]) and 19.9 % (95 % CI [-0.221, -0.177]) less for those who delivered via natural delivery in City A and City B, respectively. Conclusions: Rural hukou status is associated with younger age, no difference or lower probability of having a minimum number of prenatal checkups, higher likelihood of delivering in nontertiary hospitals, increased Cesarean delivery rates, and lower medical cost for delivery in these two Chinese cities. Evaluating how hukou status influences maternal healthcare in Chinese cities is important for devising targeted public policies to promote more equitable maternal health services. [ABSTRACT FROM AUTHOR]

Background: After achieving universal basic medical insurance coverage, Chinese government put the development of private health insurance (PHI) on its agenda to further strengthen financial risk protection. This paper aims to assess the level of financial protection that PHI provides for its insured households on the basis of resident basic medical insurance (RBMI). Methods: We employed balanced panel data collected between 2015 and 2017 from the China Household Finance Survey (CHFS). Catastrophic health expenditure (CHE) and impoverishment due to health spending were applied to measure the financial protection effects. Random effects panel logistic regression model was performed to identify the factors associated with CHE and impoverishment among households covered by RBMI. In the robustness test, the method of propensity score matching (PSM) was employed to solve the problem of endogeneity. Results: From 2015 to 2017, the CHE incidence increased from 12.96 to 14.68 % for all sampled households, while the impoverishment rate decreased slightly from 5.43 to 5.32 % for all sampled households. In 2015, the CHE incidence and impoverishment rate under RBMI + PHI were 4.53 and 0.72 %, respectively, which were lower than those under RBMI alone. A similar phenomenon was observed in 2017. Regression analysis also showed that the households with RBMI + PHI were significantly less likely to experience CHE (marginal effect: -0.054, 95 %CI: -0.075 to -0.034) and impoverishment (marginal effect: -0.049, 95 %CI: -0.069 to -0.028) compared to those with RBMI alone. The results were still robust after using PSM method to eliminate the effects of self-selection on the estimation results. Conclusions: In the context of universal basic medical insurance coverage, the CHE incidence and impoverishment rate of Chinese households with RBMI were still considerably high in 2015 and 2017. PHI played a positive role in decreasing household financial risk on the basis of RBMI. [ABSTRACT FROM AUTHOR]

Background: Cancer has become a global health problem. China still suffers continuous increasing cancer mortality. To study the trend of cancer mortality in rural China, this paper established an Age-Period-Cohort model to discuss the age effect, period effect and cohort effect on cancer mortality in rural China. Methods: The data were collected from the “China Health Statistical Yearbook” from 1990 to 2010. Collected data were analyzed by Age-Period-Cohort model and Intrinsic Estimation method. Results: The age effect on the total cancer mortality represented a V trend. Compared with Group 0–4, Group 5–9 showed 71.87% lower cancer mortality risk. Compared with Group 5–9, Group 75–79 showed 38 times higher cancer mortality risk. The period effect on the total cancer mortality risk weakened firstly but then increased. It increased by 35.70% from 1990 to 2010, showing an annual average growth of 1.79%. The cohort effect on the total cancer mortality risk weakened by totally 84.94% from 1906–1910 to 2005–2010. Three “deterioration periods” and three “improvement periods” were witnessed during this period. The malignant cancer mortality varied similarly with the total cancer mortality, while benign cancer mortality and other cancer mortality represented different variation laws. Conclusions: Although the total cancer mortality risk is increasing at an accelerated rate, cancer mortality risk in recent born year is decreasing, indicating very important impact of social change on the cancer mortality in rural China. [ABSTRACT FROM AUTHOR]

Background: Since 2020, China has piloted an innovative payment method known as the Diagnosis-Intervention Packet (DIP). This study aimed to assess the impact of the DIP on inpatient volume and bed allocation and their regional distribution. This study investigated whether the DIP affects the efficiency of regional health resource utilization and contributes to disparities in health equity among regions. Methods: We collected data from a central province in China from 2019 to 2022. The treatment group included 508 hospitals in the pilot area (Region A, where the DIP was implemented in 2021), whereas the control group consisted of 3,728 hospitals from non-pilot areas within the same province. We employed the difference-in-differences method to analyze inpatient volume and bed resources. Additionally, we conducted a stratified analysis to examine whether the effects of DIP implementation varied across urban and rural areas or hospitals of different levels. Results: Compared with the non-pilot regions, Region A experienced a statistically significant reduction in inpatient volume of 14.3% (95% CI 0.061–0.224) and a notable decrease of 9.1% in actual available bed days (95% CI 0.041–0.141) after DIP implementation. The study revealed no evidence of patient consultations shifting from inpatient to outpatient services due to the reduction in hospital admissions in Region A after DIP implementation. Stratified analysis revealed that inpatient volume decreased by 12.4% (95% CI 0.006–0.243) in the urban areas and 14.7% in the rural areas of Region A (95% CI 0.051–0.243). At the hospital level, primary hospitals experienced the greatest impact, with a 19.0% (95% CI 0.093–0.287) decline in inpatient volume. Furthermore, primary and tertiary hospitals experienced significant reductions of 11.0% (95% CI 0.052–0.169) and 8.2% (95% CI 0.002–0.161), respectively, in actual available bed days. Conclusions: Despite efforts to curb excessive medical service expansion in the region following DIP implementation, large hospitals continue to attract a large number of patients from primary hospitals. This weakening of primary hospitals and the subsequent influx of patients to urban areas may further limit rural patients' access to medical services. The implementation of the DIP may raise concerns about its impact on health care equality and accessibility, particularly for underserved rural populations. [ABSTRACT FROM AUTHOR]

Background: Inequalities in demographic, socio-economic and health status for China labor force place them at greater health risks, and marginalized them in the utilization of healthcare services. This paper identifies the inequalities which limit the utilization of health services among China labor force, and provides a reference point for health policy. Methods: Data were collected from 23,505 participants aged 15 to 65, from the 2014 China Labor Force Dynamic Survey (a nationwide cross-sectional survey covering 29 provinces with a multi-stage cluster, and stratified, probability sampling strategy) conducted by Sun Yat-sen University. Logistic regression models were used to study the effects of demographic (age, gender, marital status, type of hukou and migration status), socio-economic (education, social class and insurance) and health status (self-perceived general health and several chronic illnesses) variables on the utilization of health services (two-week visiting and hospitalization during the past 12 months). Goodness of fit was assessed using Hosmer-Lemeshow test. Discrimination ability was assessed based on the area under the receiver operating curve (AUC). Results: Migrants with more than 1 (OR 2.80, 95% CI 1.01 ~ 7.82) or none chronic illnesses (OR 1.26, 95% CI 1.01 ~ 7.82) are more likely to be two week visiting to the clinic than non-migrants; migrants with none chronic illnesses (OR 0.61, 95% CI 0.45 ~ 0.82) are less likely to be in hospitalization during the past 12 months than non-migrants. Female, elder, hukou of non-agriculture, higher education level, higher social class, purchasing more insurance and poorer selfperceived health were predictors for more utilization of health service. More insurance benefited more two-week visiting (OR 1.12, 95% CI 1.06 ~ 1.17) and hospitalization during the past 12 months (OR 1.12, 95% CI 1.07 ~ 1.18) for individuals with none chronic illness but not ≥1 chronic illnesses. All models achieved good calibration (Hosmer-Lemeshow test's P range of 0.258-0.987) and discrimination (AUC range of 0.626-0.725). Conclusions: This study has shown that there are inequalities of demographic, socio-economic and health status in the utilization of health services for China labor force. Prudent health policy with equitable utilization of health services eliminating mentioned inequalities should be a priority in shaping China's healthcare system reform. [ABSTRACT FROM AUTHOR]

Background: China initiated a health system reform in 2009 to achieve Universal Health Coverage (UHC) by 2020. While the effectiveness of health-system reforms has been studied, equity in health-service utilization and financial burden remains underexplored. This study evaluated whether the health system reform has improved the equity in utilization and financial burden of health services among patients with hypertension in China. Methods: We obtained data from four waves of the China Health and Retirement Longitudinal Study (CHARLS) conducted between 2011 and 2018. The main outcome variables were outpatient and inpatient service utilization rates and catastrophic health expenditure (CHE) for patients with hypertension. The Standardized Concentration Index (CI) was used to measure the changing equity in health service utilization and affordability. Results: Outpatient service utilization was relatively equal among patients with varying socioeconomic statuses (SESs) (CI: 0.041 in 2011 and 0.064 in 2018). Inpatient service utilization inequity improved from CI 0.144 in 2011 to CI 0.066 in 2018. CHE incidence increased from 15.6% in 2011 to 24.2% in 2018. CI for CHE declined from -0.069 in 2011 to -0.012 in 2015 but increased to -0.063 in 2018. Conclusions: Health insurance expansion and poverty alleviation policies promoted equity in inpatient service utilization for hypertensive patients. However, the financial burden for the poor requires further attention through reimbursement policy adjustments for outpatient services in primary care settings. [ABSTRACT FROM AUTHOR]

Background: The utilization of hospital delivery and antenatal care (ANC) is essential for improving maternal and newborn outcomes. However, social and cultural barriers in underdeveloped rural areas hindered maternal care utilization. This study aims to design and evaluate the effectiveness of a culturally adapted digital-platform intervention to promote maternal care utilization among women in ethnic minority communities in China. Methods: From January 1st, 2020, to December 31st, 2021, all pregnant women in Mianshan town, Liangshan Autonomous Prefecture, were invited to participate in the intervention. The multifaceted intervention included participatory and cultural-tailored health education on a popular social media platform, transportation subsidies, and capacity building and economic incentives for healthcare providers. The effectiveness of the intervention was evaluated by comparing two groups: mothers who gave live birth before the intervention (January 1st to December 31st, 2019) and mothers whose entire pregnancy period was covered by the intervention. The primary outcomes were the rate of hospital delivery and ANC utilization. Data on pregnant women were retrospectively collected through telephone surveys and the maternal and newborn's health monitoring system. Results: A total of 237 intervention sample and 138 pre-intervention sample were included. The intervention group demonstrated significantly higher rates of hospital delivery (97.5% vs. 87.7%, p < 0.001), timely initiation of ANC (73.0% vs. 62.3%, p = 0.031), and timely completion of five-time ANC visits (37.1% vs.4.3%, p < 0.001) compared to the pre-intervention group. The intervention group was more likely to utilize hospital delivery (OR = 9.26, 95%CI [2.83–30.24], p < 0.001) and ANC, including timely initiation of ANC (OR = 2.18, 95%CI [1.31–3.62], p = 0.003), completion of five ANC visits (OR = 1.72, 95%CI [1.05–2.83], p = 0.032), and timely completion of five ANC visits (OR = 15.12, 95%CI [6.24–36.64], p < 0.001). Conclusions: The culturally adapted digital-platform integrated multifaceted intervention effectively promoted the utilization of hospital delivery, timely initiation of ANC, and completion of ANC visits in the Yi ethnic community in China. This study provides valuable insights for future interventions targeting maternal healthcare services in underdeveloped ethnic minority communities worldwide. Trial registration: Chinese Clinical Trial Registry, ChiCTR2300073219. Registered 4 July 2023 - Retrospectively registered, https://www.chictr.org.cn/showproj.html?proj=199202. [ABSTRACT FROM AUTHOR]

Background: Migrants is a large population in China. To improve the health and wellbeing of migrants is a critical policy and social issue in China, and to enhance the utilization of primary health care by migrants is one of the most important approaches in promoting equity in health. However, there exists little research about the association between social integration and the utilization of primary health care. To address the research gap, this research aims at exploring the relation between social integration and the utilization of primary health care among migrants in China. Methods: Using the national data from China Migrants Dynamic Survey (CMDS) in 2017, 169,989 migrants were included in this study. Social integration was measured by social communication, acculturation and self-identity, with 8 indicators. The utilization of primary health care was measured by the receiving of health education on infectious diseases (ID) and noncommunicable diseases (NCD) as well as the first visit institution when migrants were sick. After the descriptive statistical analysis, binary logistic regression was employed to evaluate the association between social integration and the utilization of primary health care. Results: 65.99% of the migrants received health education on infectious diseases (ID), 40.11% of the migrants received health education on noncommunicable diseases (NCD) and 8.48% of the migrants chose to go to Community Health Center (CHC) seeking for health services. There was a positive effect of social organization participation, the influence of hometown customs, differences of hygiene habits between migrants and local people, integration willingness and evaluation of identity on the receiving of health education on ID and NCD, as well as a positive effect of civil activities engagement and differences of hygiene habits between migrants and local people on the utilization of CHC after getting sick. Conclusions: Social integration was associated with the utilization of primary health care among migrants in China. Generally speaking, greater social integration was associated with higher possibility of receiving health education on ID and NCD. However, the effect of social integration on the utilization of CHC was more complex among different indicators. There should be more policy interventions to improve the social integration of migrant which help them to get familiar with the health resource available, as well as improve the capacity of CHC. [ABSTRACT FROM AUTHOR]

Background: Meeting the demands of older adults for health promotion services (DOAHPS) is essential for maintaining their health and enhancing their quality of life. The purpose of this study was to construct a model for evaluating DOAHPS to quantitatively evaluate the current state and equity level of DOAHPS in China, as well as to explore the main factors affecting DOAHPS' current state and equity level. Methods: This study analyzed the DOAHPS data from the "Survey on Chinese Residents' Health Service Demands in the New Era", which included 1542 older adults aged 65 and older. Relationships between evaluation indicators of DOAHPS were explored using Structural Equation Modeling (SEM). The Weighted TOPSIS method and Logistic regression (LR) were used to analyze the current state and factors impacting DOAHPS. The equity level of DOAHPS' allocation among different older adult groups and its influencing factors were determined using the Rank Sum Ratio (RSR) method and T Theil index. Results: The evaluation score for DOAHPS was 42.57 ± 1.51. Health status, health literacy and behavior were positively correlated with DOAHPS (r = 0.40, 0.38; P < 0.05). The LR results revealed that the most significant determinants of DOAHPS were sex, residence, education level and pre-retirement occupation (all P < 0.05). The number of older adults with very poor, poor, general, high and very high level health promotion service demands accounted for 2.27%, 28.60%, 53.05%, 15.43% and 0.65%, respectively. The total T Theil index of DOAHPS was 2.7433*10–4, and the intra-group difference contribution rate exceeded 72%. Conclusions: Compared to the maximum level, the total DOAHPS level was found to be moderate, although the demands of urban seniors with higher levels of education may be substantially greater. The observed inequities in the allocation of DOAHPS were primarily related to differences in education level and pre-retirement occupation within group. To better address health promotion services for older adults, policymakers could target older males with low education who reside in rural regions. [ABSTRACT FROM AUTHOR]

Background: Allocation of healthcare resources has a great influence on treatment and outcome of patients. This study aimed to access the inequality of ambulance allocation across regions, and estimate the associations between ambulance density and pre-hospital transfer time and mortality of acute coronary syndromes (ACS) patients. Methods: This cross-sectional study was based on an integrated database of electronic medical system for 3588 ACS patients from 31 hospitals, ambulance information of 89 emergency medical stations, and public geographical information of 8 districts in Shenzhen, China. The primary outcomes were the associations between ambulance allocation and transfer delay and in-hospital mortality of ACS patients. The Theil index and Gini coefficient were used to assess the fairness and inequality degree of ambulance allocation. Logistic regression was used to model the associations. Results: There was a significant inequality in ambulance allocation in Shenzhen (Theil index: 0.59), and the inequality of inter-districts (Theil index: 0.38) was greater than that of intra-districts (Theil index: 0.21). The gap degree of transfer delay, ambulance allocation, and mortality across districts resulted in a Gini coefficient of 0.35, 0.53, 0.65, respectively. Ambulance density was negatively associated with pre-hospital transfer time (OR = 0.79, 95%CI: 0.64,0.97, P = 0.026), with in-hospital mortality (OR = 0.31, 95%CI:0.14,0.70, P = 0.005). The ORs of Theil index in transfer time and in-hospital mortality were 1.09 (95%CI:1.01,1.10, P < 0.001) and 1.80 (95%CI:1.15,3.15, P = 0.009), respectively. Conclusions: Regional inequities existed in ambulance allocation and has a significant impact on pre-hospital transfer delay and in-hospital mortality of ACS patients. It was suggested to increase the ambulance accessibility and conduct health education for public. [ABSTRACT FROM AUTHOR]

Background: Government health subsidy (GHS) is an effective tool to improve population health in China. Ensuring an equitable allocation of GHS, particularly among the poorer socio-economic groups, is a major goal of China's healthcare reform. The paper aims to explore how GHS was allocated across different socioeconomic groups, and how well the overall health system was performing in terms of the allocation of subsidy for different types of health services. Methods: Data from China's National Health Services Survey (NHSS) in 2013 were used. Benefit incidence analysis (BIA) was applied to examine if GHS was equally distributed across income quintile. Benefit incidence was presented as each quintile's percentage share of total benefits, and the concentration index (CI) and Kakwani index (KI) were calculated. Health benefits from three types of healthcare services (primary health care, outpatient and inpatient services) were analyzed, separated into urban and rural populations. In addition, the distribution of benefits was compared to the distribution of healthcare need (measured by self-reported illness and chronic disease) across income quintiles. Results: In urban populations, the CI value of GHS for primary care was negative. (− 0.14), implying an allocation tendency toward poor region; the CI values of outpatient and inpatient services were both positive (0.174 and 0.194), indicating allocation tendencies toward rich region. Similar allocation pattern was observed in rural population, with pro-poor tendency of primary care service (CI = − 0.082), and pro-rich tendencies of outpatient (CI = 0.153) and inpatient services (CI = 0.203). All the KI values of three health services in urban and rural populations were negative (− 0.4991,-0.1851 and − 0.1651; − 0.482, − 0.247and − 0.197), indicating that government health subsidy was progressive and contributed to the narrowing of economic gap between the poor and rich. Conclusions: The inequitable distribution of GHS in China exited in different healthcare services; however, the GHS benefit is generally progressive. Future healthcare reforms in China should not only focus on expanding the coverage, but also on improving the equity of distribution of healthcare benefits. [ABSTRACT FROM AUTHOR]

Background: Socio-economic inequities can strongly influence suboptimal infant feeding outcomes. Factors such as lack of knowledge about breastfeeding, low family income, low educational attainment, social and economic status, cultural norms and ethnicity may negatively affect success with offering breastfeeding following a responsive feeding approach (ie. responsive breastfeeding). Such inequities can indeed shorten breastfeeding duration, and negatively affect behavioral and cognitive infant outcomes. In China, there is a dearth of studies focusing on breastfeeding from the responsive and health equity perspective. Objective: The aim of this article is to present a protocol of an ongoing longitudinal cohort study investigating factors associated with responsive breastfeeding behaviors, and the child's behavioral and cognitive development from birth to12 months post-partum in five centers in China. The study seeks to identify breastfeeding barriers and facilitators from a health equity perspective. Methods: We are enrolling 700 women and their singleton full term infants in Chongqing, Huizhou and Guangzhou urban and rural areas. The study questionnaires will be administrated within 72 h, 30 days, 3, 6, 9, and 12 months post-partum during the baby's vaccination visits. We will investigate the difference between urban and rural areas sociodemographic characteristics, breastfeeding knowledge, attitudes and practice, postnatal depression, maternal emotion regulation and parenting stress, and anthropometric and cognitive development indicators of the infants at each time-point. Conclusion: Our article illustrates how a cohort study can be designed to understand the barriers and facilitators of responsive breastfeeding taking equity principles into account to help promote infants' growth and development in China. [ABSTRACT FROM AUTHOR]

Background: Catastrophic health expenditure (CHE) among the Chinese elderly warrants attention. However, the incidence, intensity and determinants of CHE have not been fully investigated. This study explores the incidence, intensity and determinants of CHE among elderly Chinese citizens, i.e., those aged 60 years or older. Methods: Data were obtained from three waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013 and 2015. The cut-off points used in this study for CHE were 10% of the total expenditures and 40% of non-food expenditure. Under the guidance of Andersen's model of health services utilization, this study used logistic regression analysis to explore the determinants of CHE. Results: The incidence of CHE defined as more than 40% of non-food expenditure rose over the study period, 2011–2015, from 20.86% (95% CI: 19.35 to 22.37%) to 31.00% (95% CI: 29.28 to 32.72%). The intensity of CHE also increased. The overshoot (O) based on non-food expenditure rose from 3.12% (95% CI: 2.71 to 3.53%) to 8.75% (95% CI: 8.14 to 9.36%), while the mean positive overshoot (MPO) rose from 14.96% (95% CI: 12.99 to 16.92%) to 28.23% (95% CI: 26.26 to 30.19%). Thus, the problem of CEH was even more serious in 2015 than in 2011. Logistic regression revealed that households were more likely to face CHE if they had a spouse as a household member, reported an inpatient event in the last year, reported an outpatient visit in the last month, were disabled, were members of a poor expenditure quartile, lived in the middle and western zones or resided in an urban area. In contrast, CEH was not significantly affected by respondents being older than 75 years or having a chronic health condition, by household size or by insurance type. Conclusions: Key policy recommendations include the gradual improvement of medical assistance and the expansion of the use of health insurance to reduce household liability for health expenditures. [ABSTRACT FROM AUTHOR]

Background: Driven by the government's firm commitment to promoting maternal health, maternal mortality ratio (MMR) in China has achieved a remarkable reduction over the past 25 years. Paralleled with the decline of MMR has been the expansion of hospital bed supply as well as substantial reduction in hospital bed distribution inequalities, which were thought to be significant contributors to the reduction in MMR. However, evidences on the impact of hospital bed supply as well as how its distribution inequality has affected MMR remains scarce in China. Addressing this uncertainty is essential to understand whether efforts made on the expansion of healthcare resource supply as well as on improving its distribution inequality from a geographical perspective has the potential to produce measurable population health improvements. Methods: Panel data of 31 provinces in China between 2004 and 2016 were extracted from the national statistical data, including China Statistical Yearbooks, China Health Statistical Yearbooks and other national publications. We firstly described the changes in hospital bed density as well as its distribution inequality from a geographical perspective. Then, a linear mixed model was employed to evaluate the impact of hospital bed supply as well as its distribution inequality on MMR at the provincial level. Results: The MMR decreased substantially from 48.3 to 19.9 deaths per 100,000 live births between 2004 and 2016. The average hospital bed density increased from 2.28 per 1000 population in 2004 to 4.54 per 1000 population in 2016, with the average Gini coefficient reducing from 0.32 to 0.25. As indicated by the adjusted mixed-effects regressions, hospital bed density had a negative association with MMR (β = − 0.112, 95% CI: − 0.210--0.013) while every 0.1-unit reduction of Gini coefficient suggested 14.50% decline in MMR on average (β = 1.354, 95% CI: 0.123–2.584). Based on the mediation analysis, the association between hospital bed density or Gini coefficient with MMR was found to be significantly mediated by facility birth rate, especially during the period from 2004 to 2009. Conclusions: This study provided empirical evidences on China's impressive success in the aspect of reducing MMR which could be attributed to the expansion of hospital beds as well as the improvement in its distribution inequality from a geographical perspective. Such findings were expected to provide evidence-based implications for long-term policy-making procedures in order to achieve rational healthcare resource allocations as well as promoting the equity and accessibility to obtaining health care from a holistic perspective. Constant efforts should be made on improving the equity in healthcare resource allocations in order to achieve the penetration of universal healthcare coverage. [ABSTRACT FROM AUTHOR]

Background: Continuum of care for maternal health services (CMHS) is a proven approach to improve health and safety for mothers and newborns. This study aims to explore the influence of China's 2009 healthcare reform on improving the CMHS utilisation. Methods: This population-based cross-sectional quantitative study included 2332 women drawn from the fourth and fifth National Health Service Surveys of Shaanxi Province, conducted in 2008 and 2013 respectively, before and after China's 2009 healthcare reform. A generalised linear mixed model (GLMM) was applied to analyse the influence of this healthcare reform on utilisation of CMHS. Concentration curves, concentration indexes and its decomposition method were used to analyse the equity of changes in utilisation. Results: This study showed post-reform CMHS utilisation was higher in both rural and urban women than the CMHS utilisation pre-reform (according to China's policy defining CMHS). The rate of CMHS utilisation increased from 24.66 to 41.55% for urban women and from 18.31 to 50.49% for rural women (urban: χ2 = 20.64, P < 0.001; rural: χ2 = 131.38, P < 0.001). This finding is consistent when the WHO's definition of CMHS is applied for rural women after reform (12.13% vs 19.26%; χ2 = 10.99, P = 0.001); for urban women, CMHS utilisation increased from 15.70 to 20.56% (χ2 = 2.57, P = 0.109). The GLMM showed that the rate of CMHS utilisation for urban women post-reform was five times higher than pre-reform rates (OR = 5.02, 95%CL: 1.90, 13.31); it was close to 15 times higher for rural women (OR = 14.70, 95%CL: 5.43, 39.76). The concentration index for urban women decreased from 0.130 pre-reform (95%CI: − 0.026, 0.411) to − 0.041 post-reform (95%CI: − 0.096, 0.007); it decreased from 0.104 (95%CI: − 0.012, 0.222) to 0.019 (95%CI: − 0.014, 0.060) for rural women. The horizontal inequity index for both groups of women also decreased (0.136 to − 0.047 urban and 0.111 to 0.019 for rural). Conclusions: China's 2009 healthcare reform has positively influenced utilisation rates and equity of CMHS's utilisation among both urban and rural women in Shaanxi Province. Addressing economic and educational attainment gaps between the rich and the poor may be effective ways to improve the persistent health inequities for rural women. [ABSTRACT FROM AUTHOR]

Background: China's health system has shown remarkable progress in health provision and health outcomes in recent decades, however inequality in health care utilization persists and poses a serious social problem. While government pro-poor health policies addressed affordability as the major obstacle to equality in health care access, this policy direction deserves further examination. Our study examines the issue of health care inequalities in China, analyzing both regional and individual socioeconomic factors associated with the inequality, and provides evidence to improve governmental health policies. Methods: The China Health and Nutrition Survey (CHNS) 1991-2011 data were used to analyze the inequality of health care utilization. The random effects logistic regression technique was used to model health care utilization as the dependent variable, and income and regional location as the independent variables, controlling for individuals' age, gender, marital status, education, health insurance, body mass index (BMI), and period variations. The dynamic trend of 1991-2011 regional disparities was estimated using an interaction term between the regional group dummy and the wave dummy. Results: The probability of using outpatient service and inpatient services during the previous 4 weeks was 8.6 and 1.1% respectively. Compared to urban residents, suburban (OR: 0.802, 95% CI: 0.720-0.893), town (OR: 0.722, 95% CI: 0.648-0.804), rich (OR: 0.728, 95% CI: 0.656-0.807) and poor village (OR: 0.778, 95% CI: 0.698-0.868) residents were less likely to use outpatient service; and rich (OR: 0.609, 95% CI: 0.472-0.785) and poor village (OR: 0.752, 95% CI: 0. 576-0.983) residents were less likely to use inpatient health care. But the differences between income groups were not significant, except the differences between top and bottom income group in outpatient service use. Conclusion: Regional location was a more important factor than individual characteristics in determining access to health care. Besides demand-side subsidies, Chinese policy makers should pay enhanced attention to health care resource allocation to address inequity in health care access. [ABSTRACT FROM AUTHOR]

Background: Globally people are living longer and enduring non-communicable diseases (NCDs) many of which co-occur as multimorbidity. Demographic and socioeconomic factors are determinants of inequalities and inequities in health. There is a need for country-specific evidence of NCD inequalities in developing countries where populations are ageing rapidly amid economic and social change. The study measures and decomposes socioeconomic inequality in single and multiple NCD morbidity in adults aged 50 and over in China and Ghana. Methods: The data source is the World Health Organization Study on Global AGEing and Adult Health (SAGE) Wave 1 (2007-2010). Nationally representative cross-sectional data collected from adults in China (n = 11,814) and Ghana (n = 4,050) are analysed. Country populations are ranked by a socioeconomic index based on ownership of household assets. The study uses a decomposed concentration index (CI) of single and multiple NCD morbidity (multimorbidity) covering arthritis, diabetes, angina, stroke, asthma, depression, chronic lung disease and hypertension. The CI quantifies the extent of overall inequality on each morbidity measure. The decomposition utilises a regression-based approach to examine individual contributions of demographic and socioeconomic factors, or determinants, to the overall inequality. Results: In China, the prevalence of single and multiple NCD morbidity was 64.7% and 53.4%, compared with 65.9% and 55.5% respectively in Ghana. Inequalities were significant and more highly concentrated among the poor in China (single morbidity CI = -0.0365: 95% CI = -0.0689, -0.0040; multimorbidity CI = -0.0801: 95% CI = -0.1233,-0.0368;). In Ghana inequalities were significant and more highly concentrated among the rich (single morbidity CI = 0.1182; 95% CI = 0.0697, 0.1668; multimorbidity CI = 0.1453: 95% CI = 0.0794, 0.2083). In China, rural residence contributed most to inequality in single morbidity (36.4%) and the wealth quintiles contributed most to inequality in multimorbidity (39.0%). In Ghana, the wealth quintiles contributed 24.5% to inequality in single morbidity and body mass index contributed 16.2% to the inequality in multimorbidity. Conclusions: The country comparison reflects different stages of economic development and social change in China and Ghana. More studies of this type are needed to inform policy-makers about the patterning of socioeconomic inequalities in health, particularly in developing countries undergoing rapid epidemiological and demographic transitions. [ABSTRACT FROM AUTHOR]

Background: Trust is important for health at both the individual and societal level. Previous research using Western concepts of trust has shown that a high level of trust in society can positively affect individuals' health; however, it has been found that the concepts and culture of trust in China are different from those in Western countries and research on the relationship between trust and health in China is scarce. Method: The analyses use data from the national scale China General Social Survey (CGSS) on adults aged above 18 in 2005 and 2010. Two concepts of trust ("out-group" and "in-group" trust) are used to examine the relationship between trust and self-rated health in China. Multilevel logistical models are applied, examining the trust at the individual and societal level on individuals' self-rated health. Results: In terms of interpersonal trust, both "out-group" and "in-group" trust are positively associated with good health in 2005 and 2010. At the societal level, the relationships between the two concepts of trust and health are different. In 2005, higher "out-group" social trust (derived from trust in strangers) is positively associated with better health; however, higher "in-group" social trust (derived from trust in most people) is negatively associated with good health in 2010. The cross-level interactions show that lower educated individuals (no education or only primary level), rural residents and those on lower incomes are the most affected groups in societies with higher "out-group" social trust; whereas people with lower levels of educational attainment, a lower income, and those who think that most people can be trusted are the most affected groups in societies with higher "in-group" social trust. Conclusion: High levels of interpersonal trust are of benefit to health. Higher "out-group" social trust is positively associated with better health; while higher "in-group" social trust is negatively associated with good health. Individuals with different levels of educational attainment are affected by trust differently. [ABSTRACT FROM AUTHOR]

Background Although numerous studies examine catastrophic health expenditures (CHE) worldwide, most focus on whole populations rather than specific vulnerable groups. This study analyzes the extent, associated factors and inequality of CHE in elderly household with chronic disease patients in China. Methods Data were obtained from a nationally representative elderly household survey--the China Health and Retirement Longitudinal Study--that was conducted by the National School of Development of Peking University in 2011. An elderly household with chronic disease patients is defined by = 1 chronic disease patient who is = 45 years of age. CHE was measured according to the proportion of out-of-pocket health payments to non-food household expenditures. The associated factors of CHE were estimated using ordinary least square and logistic regression modeling. CHE inequality was measured according to the concentration index (CI) and its decomposition. Results CHE incidence and intensity were relatively high among elderly households with chronic disease patients. The main associated factors of CHE include household size, having members > 65 years, having members with ≥ 2 chronic diseases, per capita income, and elderly household members demonstrating healthcare-seeking behaviors. Healthcare insurance did not significantly affect CHE risk. Disproportionate concentration of CHE was noted among elderly households, and poor elderly households demonstrated a higher probability of experiencing CHE. Factors such as household size, per capita income, having members > 65 years, and having members with ≥ 2 chronic diseases are major and positive contributors to CHE inequality. Some inpatient and outpatient services are negatively contributed to CHE inequality,suggesting that the unequal usage of such services reduces CHE inequality among elderly households with chronic disease patients. Conclusion Policy efforts should focus on improving financial protection and relieving the economic burden of disease in elderly households. The government should increase income subsidies and optimize social health insurance programs, thereby reducing CHE and alleviating CHE inequality among elderly households in China. [ABSTRACT FROM AUTHOR]

Introduction: China introduced the urban resident basic medical insurance (URBMI) in 2007 to cover children and urban unemployed adults, in addition to the new cooperative medical scheme (NCMS) for rural residents in 2003 and the basic health insurance scheme (BHIS) for urban employees in 1998. This study examined whether the overall income-related inequality in health insurance coverage improved during 2006 and 2009 in China. Methods: The China Health and Nutrition Survey (CHNS) data of 2006 and 2009 were used to create the concentration curve and the concentration index. GEE logistic regression was used to model the health insurance coverage as dependent variable and household income per capita as independent variable, controlling for individuals' age, gender, marital status, educational attainment, employment status, year 2009 (Y2009), household size, retirement status, and geographic variations. The change in the income-related inequality in 2009 was estimated using the interaction term of income*Y2009. Results: In 2006, 49.7% (4,712/9,476) respondents had health insurance: 13.4% with BHIS and 28.4% with NCMS. In 2009, 90.8% (8,964/9,863) had health insurance: 10.1% with URBMI, 18.3% with BHIS, and 57.6% with NCMS. The BHIS, URBMI, and NCMS programs had different patterns of population coverage over 10 income deciles. The concentration index was 0.15 in 2006 and 0.04 in 2009. The dominance test showed that the concentration curves were significantly different between 2006 and 2009 (p < 0.05). An income increase per capita by 10,000 RMB was associated with 25.5% more likely to have health insurance coverage (odds ratio = 1.255, 95% confidence interval: [1.130-1.393]). In 2009, there was significant improvement in the income-related inequality (p < 0.001). Discussions: Comparing 2009 to 2006, the income inequality in health insurance coverage was largely corrected in China through rapid expansion of CHNS in rural areas and initiation of URBMI in urban areas. [ABSTRACT FROM AUTHOR]

Background: Hierarchical medical systems are common in developed countries, but it's not optimistic in China. This study aimed to identify the factors affecting healthcare-seeking behavior among pregnant women in Guangdong, China. Methods: We conducted a cross-sectional, observational survey, developed using the Andersen's behavioral model. Pregnant women were randomly selected using a two-stage, stratified, random sampling method from hospitals in Guangdong, China. A multinomial logistic regression was used to identify statistically significant variables from aspect of environmental, demographic and pregnancy characteristics associated with pregnant women seeking healthcare at primary, secondary or tertiary hospitals. Results: A total of 1393 pregnant women returned the survey after attending 1 of 12 hospitals within 4 cities of the Guangdong province: 537 (38.5%) of the respondents attended a primary hospital, 437 (31.4%) a secondary hospital, and 419 (30.1%) a tertiary hospital. Women attending primary hospitals were more likely to live closer to the hospital, live rurally, and be educated to a lower level. Several factors were significantly associated with attendance at a secondary vs a primary hospital: the woman's perceived necessity to seek maternal healthcare (OR 1.73, 95% CI [1.1,2.74]), the woman's choice of delivery hospital (OR 1.45, 95% CI [1.01,2.07]), or urban living (OR 1.39, 95% CI [1.03,1.88]). Characteristics associated with attendance at a tertiary vs a primary hospital were: a history of pregnancy complications (OR 2.35, 95% CI [1.43,3.86]), travel to the hospital by public transport/taxi (OR 2.09/2.67, 95% CI [1.35,3.22]/ [1.45,4.92]), urban living (OR 1.58, 95% CI [1.14,2.18]), or a planned current pregnancy (OR 1.53, 95% CI [1.07,2.19]). Conclusion: Medical needs and convenience both play a role in the choice of hospital for antenatal care, and impact on equity utilization of health services. Pregnant women without risk factors and with higher levels of education should be a target population for guiding to choose a more proper level of hospital. [ABSTRACT FROM AUTHOR]

Background: China has an unusual pattern of suicides, with overall suicide rates in rural areas higher than urban areas. While suicide rates have decreased dramatically, older people increasingly contribute to the overall burden of suicide. However, it is unclear if elderly people within rural areas experience greater suicide risk than those in urban areas. We aimed to systematically review the incidence of suicide in rural and urban China among the elderly (aged over 60 years), with a view to describing the difference in rates between rural and urban areas and trends over time. Methods: Chinese and English language articles were searched for using four databases: EMBASE (Ovid), MEDLINE (Ovid), PsycINFO (EBSCOhost) and CNKI (in Chinese). Articles describing completed suicide among elderly people in both rural and urban areas in mainland China were included. The adapted Newcastle-Ottawa Scale (NOS) was used to assess risk of bias. One reviewer (ML) assessed eligibility, performed data extraction and assessed risk of bias, with areas of uncertainty discussed with the second reviewer (SVK). Random effects meta-analysis was conducted. Suicide methods in different areas were narratively summarised. Results: Out of a total 3065 hits, 24 articles were included and seven contributed data to meta-analysis. The sample size of included studies ranged from 895 to 323.8 million. The suicide rate in the general population of China has decreased in recent decades over previous urban and rural areas. Suicide rates amongst the elderly in rural areas are higher than those in urban areas (OR = 3.35; 95% CI of 2.48 to 4.51; I2 = 99.6%), but the latter have increased in recent years. Insecticide poisoning and hanging are the most common suicide methods in rural and urban areas respectively. Suicide rates for these two methods increase with age, being especially high in elderly people. Conclusions: The pattern of suicide in China has changed in recent years following urbanisation and aging. Differences in suicide rates amongst the elderly exist between rural and urban areas. Addressing the high suicide rate amongst the elderly in rural China requires a policy response, such as considering measures to restrict access to poisons. [ABSTRACT FROM AUTHOR]

Background: The 2015 Global Burden of Disease Study estimated that oral conditions affect 3.5 billion people worldwide with a higher burden among older adults and those who are socially and economically disadvantaged. Studies of inequalities in the use of oral health services by those in need have been conducted in high-income countries but evidence from low- and middle-income countries (LMICs) is limited. This study measures and describes socioeconomic inequality in self-reported unmet need for oral health services in adults aged 50 years and over, in China, Ghana and India. Methods: A cross-sectional analysis of national survey data from the WHO SAGE Wave 1 (2007–2010) was conducted. Study samples in China (n = 1591), Ghana (n = 425) and India (n = 1307) were conditioned on self-reported need for oral health services in the previous 12 months. The binary dependent variable, unmet need for oral health services, was derived from questions about self-reported need and service use. Prevalence was estimated by country. Unmet need was measured and compared in terms of relative levels of education and household wealth. The methods were logistic regression and the relative index of inequality (RII). Models were adjusted for age, sex, area of residence, marital status, work status and self-rated health. Results: The prevalence of unmet need was 60, 80, and 62% in China, Ghana and India respectively. The adjusted RII for education was statistically significant for China (1.5, 95% CI:1.2–1.9), Ghana (1.4, 95% CI: 1.1–1.7), and India (1.5, 95% CI:1.2–2.0), whereas the adjusted RII for wealth was significant only in Ghana (1.3, 95% CI:1.1–1.6). Male sex was significantly associated with self-reported unmet need for oral health services in India. Conclusions: Given rapid population ageing, further evidence of socioeconomic inequalities in unmet need for oral health services by older adults in LMICs is needed to inform policies to mitigate inequalities in the availability of oral health services. Oral health is a universal public health issue requiring attention and action on multiple levels and across the public private divide. [ABSTRACT FROM AUTHOR]

Background: China has seen rapid socio-economic changes and epidemiological transitions in the last few decades. Previous studies often fail to examine how wider macro-level forces contribute to changes in health inequality among its population in China. This study aims to examine urban/rural inequalities in cardiovascular (CVD) risks biomarkers among Chinese adolescents in two decades from 1991 to 2011 during the process of China's rapid urbanisation. Methods: Data were drawn from a nationwide longitudinal dataset of the China Health and Nutrition Survey (CHNS) (Sweeps 1991, 1993, 1997, 2000, 2004, 2006, 2009 and 2011). Children aged between 12 and 18 years (Boys: n = 3472; Girl: n = 3155) were included. A dynamic urbanisation index was created for each community (village or neighbourhood) based on community-level data that can reveal the heterogeneity within and across places and capture dimensions of social, economic and physical characteristics of urban living over time and space. Linear multilevel modeling analyses (Level 1: Occasions; Level-2: Individuals; Level-3: Households; Level-4: Communities) were performed on outcomes of CVD risk biomarkers including anthropometric measures and blood pressure. Results: After adjustment for age, maternal education and household income per capita, cardiovascular (CVD) risk biomarkers increase among Chinese adolescents during 1991 to 2011. Urbanisation tends to have an independent and positive impact on body mass index (BMI) and waist circumference for boys but not for girls. Positive interaction effect between urbanisation index and survey years for waist circumference was observed for girls (0.005; 95% confidence interval [CI], 0.002, 0.007; p < 0.01): time trends become greater when areas become more urbanized. For blood pressure, when areas become more urbanized the trends for boys become decreased (− 0.005; 95% CI, − 0.009, − 0.002; p < 0.01 for systolic blood pressure and − 0.003; 95% CI, − 0.006, − 0.001; p < 0.05 for diastolic blood pressure). Conclusion: Chinese adolescents are experiencing an upward trend of cardiovascular (CVD) risks in last two decades. Its rapid urbanisation appears to further increase urban/rural inequalities in CVD risks, especially for boys from less urbanised areas and girls from more urbanised areas, which may contribute to the development of cardiovascular disease (CVD) in adulthood. It is relevant to inform policy making process to target specific vulnerable groups. Given China's urbanisation is strongly influenced by the state, there is a possibility for policy intervention to reduce inequality during the process of China's planned urbanisation. [ABSTRACT FROM AUTHOR]

Background: Abdominal obesity has become an important public health issue in China. Socioeconomic disparities are thought to be closely related to the prevalence of abdominal obesity. Exploring socioeconomic disparities in abdominal obesity over the life course in China could inform the design of new interventions to prevent and control abdominal obesity. Methods: The China Health and Nutrition Survey (CHNS) was a prospective household-based study involving seven rounds of surveys between 1993 and 2011. Twenty three thousand, two hundred and forty-three individuals were followed up over an 18-year period. The mixed effects models with random intercepts were used to assess the effects on abdominal obesity. Six key socioeconomic indicators, with age and age-squared added to the models, were used to identify socioeconomic disparities in abdominal obesity over the adult life course. Results: Prevalence of abdominal obesity increased non-linearly with age over the adult life course. Abdominal obesity was more prevalent in younger than older birth cohorts. Positive period effects on the prevalence of abdominal obesity were substantial from 1993 to 2011, and were stronger among males than females. Prevalence of abdominal obesity was higher among ethnic Han Chinese and among the married [coefficient (95% confidence intervals): 0.03(0.003, 0.057) and 0.035(0.022, 0.047), respectively], and was lower among males [coefficient (95% confidence intervals): − 0.065(− 0.075,-0.055)]. A higher-level of urbanization and higher household income increased the probability of abdominal obesity [coefficient (95% confidence intervals): 0.160(0.130, 0.191), 3.47E− 4 (2.23E− 4, 4.70E− 4), respectively], while individuals with more education were less likely to experience abdominal obesity [coefficient (95% confidence intervals): − 0.222 (− 0.289, − 0.155)] across adulthood. Conclusions: In China, abdominal obesity increased substantially in more recent cohorts. And people with lower educational attainment, with higher household income, or living in more urbanized communities may be the disadvantaged population of abdominal obesity over the adult life course. Effective interventions targeting the vulnerable population need to be developed. [ABSTRACT FROM AUTHOR]

Background: Beginning in 2010, China has endeavoured to expand health coverage and provide residents with fair access to primary health care with the intention of improving health equity. This study aims to measure changes in income-related health inequity in China between 2010 and 2014. Methods: Data were extracted from the nationally representative annual survey of the China Family Panel Studies in 2010 and 2014 with a first wave of 31,743 respondents and a second wave of 32,006 respondents over age 15. In both years, subjects were stratified into the following five categories of income: poorest 20%, lower 20%, medium 20%, higher 20% and richest 20%. The concentration curve and index was used to compare the distribution of health status in income quintiles, and a logistic model was used to examine the relationship between health and socioeconomic indicators with self-assessed health as the primary outcome of interest. Results: Income was significantly associated with self-assessed health in China. The concentration curve was above the line of equality in both years, while the self-assessed health line in 2014 was closer to the equality line. The concentration index (CIN) displayed the similar result of decreasing inequality, with the CIN in 2014 (− 0.157) closer to zero (the line of equality) than that of 2010 (− 0.167). In 2010, there was a decreasing trend of people reporting poor health from the poorest to the richest, while in 2014, there was no significant difference between the poorest and lower 20% or between the higher 20% and the medium 20%. The odds ratio of the prevalence of self-reporting poor health between the poorest and richest increased from 0.555 (95% CI: 0.484–0.636) in 2010 to 0.598 (95% CI: 0.513–0.696) in 2014. Conclusions: From 2010 to 2014, the self-assessed health gap between income groups in China decreased, and health equity improved. However, health differences remain. In order to achieve better health for all, China should further strengthen the role of primary care in reducing health inequity. [ABSTRACT FROM AUTHOR]

Background: The inequality of health human resource is a worldwide problem, and solving it also is one of the major goals of China’s recent health system reform. Yet there is a huge disparity among cities in mainland China. The aim of this study is to analyze the distribution inequality of the health human resource in 322 prefecture-level cities of mainland China in 2014, and to reveal the facets and causes of the inequalities. Methods: The data for this study were acquired from the provincial and municipal Health Statistics Yearbook (2014) and Statistical Yearbook (2014), the municipal National Economic Bulletin (2014), and the official websites of municipal governments, involving 322 prefecture-level cities. Meanwhile, Concentration Index was used to measure the magnitude of the unequal distribution of health human resource. A decomposition analysis was employed to quantify the contribution of each determinant to the total inequality. Results: The overall concentration index of doctors and nurses in mainland China in 2014 was 0.1038 (95% CI = 0.0208, 0.1865) and 0.0785 (95% CI =0.0018, 0.1561). Decomposition of the concentration index revealed that economic status was the primary contributor (58.5% and 57%) to the inequality of doctors and nurses, followed by the Southwest China (19.1% and 18.6%), urbanization level (− 13.1% and − 12.8%), and revenue (8.0% and 7.8%). Party secretaries with Master degree (7.0%, 6.8%), mayors who were 60 years old or above (6.3%, 6.1%) also were proved to be a major contributor to the inequality of health human resource. Conclusions: There was inequality of health human resource distribution which was pro-rich in mainland China in 2014. Economic status of the cities accounted for most of the existing inequality, followed by the Southwest China, urbanization level, revenue, party secretaries with Master degree, and mayors who were 60 years old or above in respective importance. Besides, the party secretaries and mayors also had certain influence on the allocation of health human resource. The tough issue of HHR inequality should be addressed by comprehensive measures from a multidisciplinary perspective. [ABSTRACT FROM AUTHOR]