In this study, a comparison of choices of first-contact care in Zhejiang and Qinghai was carried out. It was found that the proportion of residents who chose PHIs as their first-contact care medical institutions of Zhejiang was lower than that of Qinghai. The HI index was used to assess horizontal equity when selecting first-contact care among residents with similar health needs. Pro-poor inequity in Zhejiang and mild pro-rich inequity in Qinghai were found. Inequity was greater among the poor in rural regions in the two provinces.
In total, the proportion of residents selecting PHI as their first-contact care in Zhejiang was lower than that in Qinghai. One possible reason for the difference is the gaps in medical insurance between different institution levels. Prior studies reported that medical insurance plays an important role in the NHMS [3, 9]. The gaps in medical package benefits between different institution levels for Qinghai was larger than that for Zhejiang [24, 25]. In Qinghai, for outpatients with urban and rural medical insurance (URRMI), the reimbursement ratio was 50% with a ceiling of 120 per capita per year; for outpatients with URRMI, the deductible was 100, 600, and 1500, and the reimbursement ratio was 90%, 80%, and 70% for PHI, secondary hospitals, and tertiary hospitals, respectively [24]. For Zhejiang, using Jiaxing as an example, for outpatients with URRMI, the reimbursement ratio were 40%, 20%, and 10% for PHI, secondary hospitals, and tertiary hospitals, respectively; for inpatients with URRMI, the deductibles were 300, 500, 1000, and the reimbursement ratio were 80%, 75% and 65% for PHI, secondary hospitals, and tertiary hospitals, respectively [26]. The larger gaps in deductibles and reimbursement in Qinghai may encourage resident to use PHI more. In addition to the difference in medical insurance package, Qinghai was at the forefront of implementation of the NHMS in China in 2013, while Zhejiang developed several pilot programs in 2014 [25]. Compared with Zhejiang, residents had more time to get used to NHMS in Qinghai, which might help to increase the utilization of PHI.
With similar health needs, the degree of pro-poor inequity of Zhejiang was significant; poorer residents preferred to select PHI as their first-contact care. In Qinghai, a mild pro-rich inequity can be found, and richer residents preferred to select PHIs. Zhejiang is a relatively developed province in China, with 56.56 million inhabitants; its annual gross domestic product was 7793.69 billion dollars in 2017 [27]. Compared with Zhejiang, Qinghai is underdeveloped, with 5.98 million inhabitants, and its annual gross domestic product was 39.14 billion dollars in 2017 [28, 29]. Also, as demonstrated in this study, the income per capita per year in Zhejiang was significantly higher than that in Qinghai. Rich residents in Zhejiang may not be as sensitive to the differences in reimbursement ratio for different institution levels, which may be because the differences for them are not as significant. For Qinghai, the choices of first-contact care were almost equitable. The overall income level in Qinghai was moderate. Considering the larger gaps in reimbursement between different institution levels in Qinghai, residents with different SES status may be more likely to select PHI as their first-contact care equally.
A subgroup analysis of region type (urban or rural) was also carried out. Results indicated that the pro-poor inequity was more serious in urban regions in the two provinces. In Zhejiang, a pro-poor inequity can be found both in rural and urban regions; however, the degree of inequity was more serious among urban residents. In Qinghai, in rural regions, rich residents tended to select PHI, whereas in urban regions, more poor residents selected PHI. One possible reason for this finding may be the urban-rural income gap, which is about 2.02:1 [30]. Compared with rural residents, urban residents were richer; therefore, they may be less sensitive to the gaps in medical reimbursement between different levels of institutions when they select first-contact care providers. This situation could result in richer residents preferring not to select PHIs for first-contact care in urban regions.
These findings showed that for a country with vast land and a tremendous amount of regional socioeconomic differences, medical reform should be implemented according to local conditions. The focus of the reform should be based on socioeconomic development. For Zhejiang, residents were relatively richer, and they would be less sensitive to the gaps in medical insurance reimbursement, larger gap in the medical reimbursement ratio or other solutions can be employed to increase the utilization of PHI, especially in urban regions. For Qinghai, with similar health needs, the choices of first-contact care were almost equitable, which may serve as an example for other regions. However, the equitable utilization of PHI in rural regions of Qinghai should be further promoted.
This study had several limitations. First, possible reasons based on prior research and information from government websites were considered to explain the findings; however, not all possible factors were discussed in the study. Second, residents may have forgotten actions taken in the past regarding their health care, causing recall bias. Because the questionnaires were administered to each household, it is likely that family members discussed these past actions for better recall. Third, there were many proper nouns in the questionnaires, which may cause misunderstanding of residents. We added the explanation of these nouns, and face-to-face questionnaires were carried out to decrease misunderstandings.
There are three major policy implications from this study. First, medical reform policies should take socioeconomic status into consideration, developing different policies for different regions. Second, more focus should be placed on urban regions, in order to increase the equitable utilization of PHIs. Third, larger gaps in reimbursement at different institution levels may help increase the equitable utilization of PHIs.