Inequalities in health and healthcare : a study of internal migrants in Shenzhen, China

Abstract

The Hukou registration system in China, through which healthcare and other social benefits are made available, has created a unique divide in the population as many Hukou holders from the rural areas of poverty migrate to urban areas of relative wealth, where they lack the urban Hukou and become non-Hukou holders (migrants). Recent health-reforms and migrants-specific policies have promised to deliver greater equity in the distribution of social benefits, such as health insurance, and reduce inequalities in access to healthcare for non-Hukou holding migrants in host cities. This study will quantify the impact of these disparities and inequities between migrants and registrants in a host city. The objectives of this study were to examine equity in the distribution of social health insurance amongst non-Hukou (migrants) and Hukou holders (registrants), describe enrolment and benefit differences in social insurance and private insurance and the impact of each in reducing out-of-pocket financed utilisation by Hukou status, examine equalities in access to healthcare services based on Hukou status and health needs, and explore alternative health-seeking behaviours for migrants. Two large cross-sectional studies (Study 1: n=1,543; Study 2: n=1,533) over an 18 month study period were used to assess healthcare utilisation using the Andersen health behaviour model. Multivariate logistic regression models were used to determine the association between access to healthcare as proxied by self-reported utilisation of out-patient and in-patient service and Hukou status; a generalised linear model with gamma log-link was adopted to examine out-of-pocket payment and healthcare utilisation; univariate analysis were used to describe health insurance coverage, and health needs; and several health and healthcare need related factors were assessed, such as chronic health conditions and depressive symptoms. Inequity in distribution of social insurance by Hukou status remains, despite recent reform efforts to increase overall coverage for non-Hukou holding migrants. Private health insurance coverage was more prevalent amongst non-Hukou migrants, but was shown to be ineffective at reducing out-of-pocket (OOP) expenditures for out-patient services. Non-Hukou migrants report less utilisation of healthcare services and pay significantly more OOP payments for the care they receive than registrants. Inequalities in access to healthcare is demonstrated for those without Hukou, despite greater health needs (higher prevalence of smoking, higher prevalence of depression, lower levels of physical activity) and exhibit alternative health-seeking behaviours. Recent health reforms and migrant-specific policies have yet to deliver an equitable distribution of social benefits, and healthcare inequalities remains between individuals of different Hukou status in the same city. Considering the importance of migrants to China’s continual development and economy, future health policies and Hukou reforms must resolve existing inequalities induced by the Hukou system.