Trends and projections of universal health coverage indicators in China, 1993-2030: An analysis of data from four nationwide household surveys.

Universal health coverage (UHC) is a core element of Sustainable Development Goals and has become a global healthcare priority. China has been committing to provide all citizens with affordable and equitable basic healthcare over past decades. However, progress towards UHC in China has not been comprehensively assessed. This study aims to comprehensively evaluate the progress towards UHC in China by examining trends in service coverage and financial protection from 1993 to 2018, and estimating the probability of achieving UHC targets by 2030. Following the framework proposed by World Health Organization and World Bank, we selected 12 prevention service indicators, 12 treatment service indicators, and two financial protection indicators to evaluate China's progress towards UHC. We used data from four nationally representative household surveys to assess the trends in service coverage and financial protection between 1993 and 2018, as well as their inequalities across subgroups. Meta-analysis was used to construct the composite prevention and treatment indices. The regression-based relative index of inequality was used to measure the income-related inequality of UHC indicators. Bayesian linear regression was conducted to predict progress towards UHC by 2030, and the probability of achieving UHC targets. Of the 24 service coverage indicators used in this study, most of them experienced improvements between 1993 and 2018. The composite prevention index increased from 65.6% (95% CI: 52.1%-77.9%) to 87.7% (95% CI: 81.8%-92.6%) and the composite treatment index increased from 57.1% (95% CI: 43.5%-70.1%) to 75.5% (95% CI: 66.6%-83.5%). The inequalities of service coverage experienced significant declines during this period. Based on our projections, most indicators except ones in the area of non-communicable diseases (NCD) will achieve the 80% coverage target by 2030, and the prevention and treatment indices will increase to 92.7% (95% CrI: 90.3%-94.7%) and 83.2% (95% CrI: 75.1%-88.8%) by then. However, we observed limited reductions in the incidences of catastrophic health expenditure and medical impoverishment. Inequalities in financial protection remained large in 2018. China had made significant progress in improving healthcare service coverage and reducing inequalities between 1993 and 2018. However, China faces great challenges in improving financial protection and controlling NCD on its path towards UHC. Establishment of a primary-healthcare-based integrated delivery system and provision of better financial protection for vulnerable population should be prioritized. None.

Li Y ，Zhang C ，Zhan P ，Fu H ，Yip W ... -  《-》

Trends in, and projections of, indicators of universal health coverage in Bangladesh, 1995-2030: a Bayesian analysis of population-based household data.

Many countries are implementing health system reforms to achieve universal health coverage (UHC) by 2030. To understand the progress towards UHC in Bangladesh, we estimated trends in indicators of the health service and of financial risk protection. We also estimated the probability of Bangladesh's achieving of UHC targets of 80% essential health-service coverage and 100% financial risk protection by 2030. We estimated the coverage of UHC indicators-13 prevention indicators and four treatment indicators-from 19 nationally representative population-based household surveys done in Bangladesh from Jan 1, 1991, to Dec 31, 2014. We used a Bayesian regression model to estimate the trend and to predict the coverage of UHC indicators along with the probabilities of achieving UHC targets of 80% coverage of health services and 100% coverage of financial risk protection from catastrophic and impoverishing health payments by 2030. We used the concentration index and relative index of inequality to assess wealth-based inequality in UHC indicators. If the current trends remain unchanged, we estimated that coverage of childhood vaccinations, improved water, oral rehydration treatment, satisfaction with family planning, and non-use of tobacco will achieve the 80% target by 2030. However, coverage of four antenatal care visits, facility-based delivery, skilled birth attendance, postnatal checkups, care seeking for pneumonia, exclusive breastfeeding, non-overweight, and adequate sanitation were not projected to achieve the target. Quintile-specific projections showed wide wealth-based inequality in access to antenatal care, postnatal care, delivery care, adequate sanitation, and care seeking for pneumonia, and this inequality was projected to continue for all indicators. The incidence of catastrophic health expenditure and impoverishment were projected to increase from 17% and 4%, respectively, in 2015, to 20% and 9%, respectively, by 2030. Inequality analysis suggested that wealthiest households would disproportionately face more financial catastrophe than the most disadvantaged households. Despite progress, Bangladesh will not achieve the 2030 UHC targets unless the country scales up interventions related to maternal and child health services, and reforms health financing systems to avoid high dependency on out-of-pocket payments. The introduction of a national health insurance system, increased public funding for health care, and expansion of community-based clinics in rural areas could help to move the country towards UHC. Japan Ministry of Health, Labour, and Welfare.

Rahman MS ，Rahman MM ，Gilmour S ，Swe KT ，Krull Abe S ，Shibuya K ... -  《Lancet Global Health》

Inequalities in non-communicable disease management in China and progress toward universal health coverage: an analysis of nationwide household survey data from 2004 to 2018.

Zhou Y ，Wu Q ，Li C ，Meng P ，Ding L ... -  《-》

Universal health coverage in China: a serial national cross-sectional study of surveys from 2003 to 2018.

Achieving universal health coverage (UHC) is one crucial target of the Sustainable Development Goals. However, consistent trends data for UHC evaluation in China are still scarce. The aim of our study was to provide a comprehensive assessment of UHC in China. In this serial cross-sectional study, we collected nationally representative data from the latest four rounds (2003, 2008, 2013, and 2018) of the National Health Service Surveys, with the aim of evaluating UHC in China. These surveys used multistage stratified cluster sampling covering all 31 provinces, autonomous regions, and municipalities in mainland China. Within each household, all members aged 15 years and older were interviewed. For children and adolescents aged younger than 15 years, their adult family members answered the questions for them. We constructed a UHC index following the WHO-recommended framework that included service coverage (nine prevention indicators and five treatment indicators) and financial protection (three indicators) dimensions. Bayesian regression models were done to investigate the trends in and projections of UHC index and indicators, with average annual percentage change (AAPC) and probabilities of achieving the 2030 WHO targets. Based on trends and projections, we counted population equivalents with UHC coverage. To examine the potential efficiency of financial investment, we quantified UHC performance based on government health expenditure (GHE) per capita. Finally, we explored the association between each UHC indicator and macroeconomic and health systems characteristics by using multiple regression. We sampled 57 023 households from 95 counties between September and October, 2003; 56 456 households from 94 counties between June and July, 2008; 93 613 households from 156 counties between August and October, 2013; and 94 076 households from 156 counties in September, 2018. A total of 901 182 individuals were involved in this study (193 689 in 2003, 177 501 in 2008, 273 688 in 2013, and 256 304 in 2018). Although the overall UHC increased from 44·0% (95% CI 43·0-44·9) in 2003 to 79·8% (79·2-80·3) in 2018 and is predicted to meet the 80% global target by 2030, the progress towards UHC has steadily slowed down nationally. Based on current projections, an estimated 105·8 (95% CI 27·3-189·1) million population equivalents would still not have UHC coverage in 2030. The treatment index showed a large increase over time from 2003 to 2018 (AAPC 4·9%, 2·9-7·2), with minimal disparities and all subgroups will achieve the target in the treatment domain by 2030 (possibilities higher than 90%). However, the prevention index presented poor performance with a small increase over time from 2003 to 2018 (AAPC 1·4%, 0·3-2·5) and sizable disparities across regions, urban-rural areas, and income (all p<0·0001). To achieve at least 80% UHC coverage, provinces would need to reach at least ¥445 in GHE per capita per year under maximum efficiency. However, large gaps between the observed and frontier UHC index, especially in several western provinces, indicated inefficiency. Furthermore, we found that primary health-care institutions were closely and positively related to UHC indicators especially in the prevention domain. Although considerable achievements have been made, the progress towards UHC is not keeping pace with the rapid society development in China. Considering an increased burden in non-communicable diseases and an ageing population, prioritising the efficacy of financial investment and optimising resource allocation by strengthening primary health care are necessary to achieve UHC in China. National Natural Science Foundation of China and National Health Commission of the People's Republic of China.

Zhou Y ，Li C ，Wang M ，Xu S ，Wang L ，Hu J ，Ding L ，Wang W ... -  《The Lancet Regional Health》

Provincial inequality of China's progress towards universal health coverage: An empirical analysis in 2016-21.

Achieving universal health coverage (UHC) is a crucial target shared by the Sustainable Development Goals (SDGs). As UHC levels are influenced by factors such as the regional economy and resource allocation, subnational evidence in China is urgently needed. This study aimed to monitor provincial progress from 2016 to 2021, thereby informing the development of region-specific strategies. Based on the UHC monitoring framework proposed by the World Health Organization, a UHC index was constructed comprising the service coverage dimension (16 indicators) and financial protection dimension (four indicators). In this observational study, routinely collected health data from 25 provinces (autonomous regions and municipalities) in mainland China were obtained from statistical yearbooks, relevant literature, and nationally representative surveys. The indices were calculated using geometric means. Socioeconomic inequalities among provinces were quantified using the slope index of inequality (SII) and relative index of inequality (RII). From 2016 to 2021, China made laudable progress towards achieving UHC, with the index rising from 56.94 in 2016 to 63.03 in 2021. Most provinces demonstrated better performance in service coverage. Western provinces generally presented faster rates of progress, which were attributed to more substantial increases in financial protection. Despite significant disparities, with the UHC index ranging from 77.94 in Shanghai to 54.61 in Fujian in 2021, the overall equity of UHC has improved across the 25 provinces. SII decreased from 17.78 (95% confidence interval (CI) = 11.64, 23.93) to 12.25 (95% CI = 5.86, 18.63) and RII from 1.38 (95% CI = 1.29, 1.46) to 1.22 (95% CI = 1.16, 1.29). However, the non-communicable disease (NCD) domain experienced a drop in both index score and equity, underscoring the need for prioritised attention. In the context of SDGs and the 'Healthy China 2030' initiative, China has made commendable progress towards UHC, and inter-provincial equity has improved. However, substantial differences persisted. The equitable realisation of UHC necessitates prioritising the enhancement of service capacity and financial protection in less developed regions, particularly by addressing shortages in the general practitioner workforce and mitigating catastrophic payments. Developed regions should focus on preventing NCDs through effective interventions targeting key risk factors. This study provides insights for other countries to adopt comprehensive monitoring frameworks, identify subnational disparities, and introduce targeted policy initiatives.

Wang Y ，Wang R ，Jiang M ，Ying X ... -  《-》