Health Disparities in China

Karen Eggleston speaking to staff at Zhejiang Provincial CDC, China

Addressing Health Disparities in China

Insights from Tongxiang county

Peering into China’s longevity strategies

A collaborative research project looks to Tongxiang county in Zhejiang, one of China’s most developed provinces, as a case study instructive for the country’s responses to healthcare inequalities and population aging challenges in rural and urban areas.

Research Focus

Tongxiang is a mostly rural county in Zhejiang, one of China’s most developed provinces. It is home to a population of about 700,000 registered residents, of whom the majority are rural (agricultural) hukou residents and the minority are urban (non-agricultural) hukou residents. The hukou system of household registration strongly marks and shapes socio-economic status and access to social programs in China. Hukou status is determined at birth, cannot easily be changed, and dictates many of the social programs to which a resident is entitled, such as education, healthcare, and old-age support. For example, historically, firms do not pay social security benefits for agricultural hukou workers but are required to pay for non-agricultural hukou workers.
How is China poised to tackle inequalities in healthcare spending and health outcomes among rural and urban populations? How will the country develop strategies for healthy aging in rural versus urban areas? Studying Tongxiang residents with urban and rural hukou may offer insights into these questions.
The Addressing Health Disparities in China project, led by Shorenstein APARC’s Asia Health Policy Program (AHPP), focuses on two areas:
First, it investigates the different health and medical care experiences of residents with urban and rural hukou. Tongxiang citizens have two main healthcare options available to them: the clinic and the regional hospital, and patients are free to choose which source of healthcare they utilize. The study will describe the different patterns of healthcare utilization by urban versus rural patients. It will also evaluate the efficiency of the current system by conducting a cost-benefit analysis of a hypothetical move to a “gatekeeper system,” a structure in which patients would have to see a doctor at the clinic in order to get a referral for a specialist.
This analysis requires an evaluation of how patients in Tongxiang make healthcare choices, which may differ according to their life-course exposures to urban and rural environments and their associated privileges and constraints. What do they value and what constraints do they face? Varying commute length, varying severity of illness, age, education, credit constraints, and individual insurance design all might influence a patient’s choice of visiting a clinic or a specialist. Evaluating these values may be the work product of creating general “maps” of how patients navigate the healthcare system. By analyzing how patients with chronic illnesses navigate their treatment in the current system, this study can help evaluate the system and make predictions about a hypothetical new one.
Second, the study assesses the impact of catastrophic coverage for inpatient services among those covered by resident insurance. This 2014 insurance expansion had two related effects on benefits: it removed the cap on how much insurance can cover and it significantly lowered the out-of-pocket payment requirements for resident insurance beneficiaries. The study examines the impact of this insurance expansion on Tongxiang citizens. It uses machine learning techniques and extensive data from medical claims as well as the local population health management system—frequently an unobserved, confounding factor in such studies.
Tongxiang’s health system features two social health insurance schemes: the employee health insurance scheme and the resident health insurance scheme. Most agricultural hukou residents in Tongxiang only qualify for the resident insurance scheme. The study also uses a difference-in-difference approach to explore the spending and health outcome changes before and after the 2014 insurance expansion.
The project builds upon a previous initiative of the Zhejiang Provincial CDC, AHPP Director Karen Eggleston, and Stanford economics student Yiwei Chen. The Zhejiang CDC-Eggleston collaboration compiled and linked several important individual-level and household-level datasets related to the health and survival of Tongxiang residents, resulting in the most comprehensive micro health data for studying health insurance schemes in China.

Lead Researchers and Collaborators


Karen Eggleston

APARC Deputy Director and Asia Health Policy Program Director

Karen Eggleston

APARC Deputy Director and Asia Health Policy Program Director
Senior Fellow, Freeman Spogli Institute for International Studies
Fellow at the Center for Health Policy and the Center for Primary Care and Outcomes Research

Stefan Wager

Assistant Professor of Operations, Information, and Technology at Stanford’s Graduate School of Business

Stefan Wager

Assistant Professor of Operations, Information, and Technology at Stanford’s Graduate School of Business
Assistant Professor of Statistics (by courtesy), School of Humanities and Sciences


The Effects of Chronic Disease Management in Primary Health Care: Evidence from Rural China 
Journal of Health Economics, November 2021

The Impact of Catastrophic Medical Insurance in China: A Five-Year Patient-Level Panel Study
The Lancet Regional Health - Western Pacific, July 2021
See also "In China, Better Financial Coverage Increases Healthcare Access and Utilization," APARC website, July 2021

False Alarm? Estimating the Marginal Value of Health Signals
Journal of Public Economics, February 2021

Future Projection of the Health and Functional Status of Older People in Japan: A Multistate Transition Microsimulation Model with Repeated Cross‐Sectional Data
Health Economics, July 2020

China’s Evolving Healthcare Ecosystem: Challenges and Opportunities
Testimony before the U.S.-China Economic and Security Review Commission, May 2020

Healing One-Fifth of Humanity: Progress and Challenges for China's Health System
Milken Institute Review, October 2019

Enhancing Financial Protection under China’s Social Health Insurance to Achieve Universal Health Coverage
BMJ, June 2019

The Impact of Social Pensions on Intergenerational Relationships: Comparative Evidence from China
Journal of the Economics of Ageing, November 2018
BMJ Open, November 2018
The China Quarterly, May 2017