LAUSR

Abstract Background New Rural Cooperative Medical Scheme (NCMS) in China rapidly achieved over 90% population coverage since its launch in 2003, and then gradually improved its service coverage and financial protection. Most published studies were conducted in the early years of NCMS or only focused on sub-regions in China. We aimed to provide the first national, comprehensive and up-to-date assessment of the equity of effects of NCMS on service use, medical financial burden, and health from 2003 to 2013. Methods Using three waves of the National Health Service Surveys in 2003, 2008, and 2013 (total sample size >600 000 individuals), we classified NCMS enrollees into five income quintiles and analysed national trends in health service use, and catastrophic expenditure over the study period. To further examine the effects of NCMS on trends of catastrophic medical expenditure across income quintiles, three multi-variate logistic regression models were used. Findings From 2003 to 2013, inequity in health service use was greatly reduced with respect to income. In 2013, prevalence of outpatient service use was 14·5% in the lowest income quintile and 13·2% in the highest income quintile; prevalence of inpatient service use was 8·6% in the lowest and 7·8% in the highest income quintile. In 2003, prevalence of outpatient service use was 13·5% in the lowest income quintile and 15·2% in highest income quintile; prevalence of inpatient service use was 1·8% in the lowest and 4·1% in the highest income quintile. Contradicting previous findings of increased financial burden after NCMS implementation, we identified improvements in financial risk protection (odds ratio 0.66, 95% CI 0·57–0·77, for catastrophic medical expenditure in 2013 relative to 2003). The proportion of households with catastrophic medical expenditure only increased in the lowest income quintile (from 16·1% in 2003 to 24·7% in 2013) but decreased in all other income quintiles. Interpretation Improvements in health equity and financial risk protection were seen after 10 years of the NCMS. However, medical financial burdens increased among the poorest people, highlighting the importance of targeting the lowest-income rural residents in future reforms of rural health insurance and medical financial assistance. Funding This study did not receive funding from any agency.