Disparities in Access to Healthcare: Children in Shanghai, China

Background and Purpose: China is facing a healthcare crisis in the lack of pediatricians available to children and their families (Xu & Zhang 2014). Despite major health insurance reforms in 2009 that expanded health insurance to make the system more accessible and affordable, issues still remain (Cao et al. 2012; Qingyue & Shenglan 2013). The healthcare system in China is fragmented, and health insurance type for children varies by household registration (hukou) status, parental employment status, and region (Cao et al. 2012; Meng et al. 2015). The variety and fragmentation of health insurance types inevitably leads to benefit gaps (Qingyue & Shenglan, 2013). The description of the varied system in China certainly echoes what we know about the US healthcare system. One important difference that compounds healthcare access disparities in China is the striking shortage of pediatricians (Xu & Zhang 2014). This shortage has the potential to exacerbate socioeconomic disparities in access to health care for Chinese children, and has attracted public attention in China and internationally. In fact, with day long waits, the growing practice of professional queue waiting, and the selling of pediatric appointment times may make it more difficult for poor families to get necessary care. This paper examines the socioeconomic disparities in access to healthcare for school age children in Shanghai, China and contextualizes these disparities through a comparison to the US.

Method: We use the 2014 Child Well-Being Study of Shanghai, China—a study modeled on child cohort studies in the US. The sample of approximately 2,000 children is 7 years of age on average at the time of survey in 2014. We perform logistic regression models using clustered robust standard errors to estimate adjusted odds ratios of never having regular health care visits by family income tercile, district income tercile, maternal education and household registration (hukou) status, controlling for a set of sociodemographic variables. To explore the relationships among socioeconomic status, health insurance coverage, and regular health care visit, we compare results from the above models with those from models with a restricted sample of insured children. We contextualize these findings using US healthcare access data from the National Health Interview Survey.

Results: We find that about 20% of children in our sample have never had a regular primary care visit. The results from logistic regression models indicate that children from low-income families, low-income districts, families with low maternal education attainment, and with a rural household registration are significantly at risk of exclusion from regular medical care. The result holds in corresponding models including only insured children. These disparities in access to care are greater than in the US.

Conclusions and Implications: Despite recent healthcare reform, children from low socioeconomic families in Shanghai, China face serious obstacles to obtaining healthcare. Our results shed light on the importance of social welfare programs and healthcare reform in Shanghai to address this issue, and the optimal roles and functions of social workers to improve overall child wellbeing in rapidly changing China.