Economic status and catastrophic health expenditures in China in the last decade of health reform: a systematic review and meta-analysis
Open accessAbstract
Background: In order to solve the problem of “expensive medical treatment and difficult medical treatment” for patients and improve the equity of medical services, China started the health-care reform in 2009, and proposed ambitious goals of providing fair and high-quality basic medical and health services to all citizens and reducing economic burden of diseases. This study was to systematically explore the association between population economic status and incidence of catastrophic health expenditures (CHE) in mainland China in the last decade since 2009 health reform. Methods: This systematic review was reported according to the standard of preferred reporting items for systematic reviews and meta-analyses (PRISMA). We systematically searched Chinese Electronic literature Database of China Journal Full Text Database, Chinese Biomedical Journal Database, Wan fang Data Resource System, VIP Database, and English literature databases of PubMed, SCI, EMbase and Cochrane Library from January 2000 to June 2020, and references of included studies. Two reviewers independently selected all reports from 2000 to 2020 for empirical studies of CHE in mainland China, extracted data and evaluated the quality of the study. We conducted meta-analysis of the incidence of CHE and subgroup analysis according to the time of the study and the economic characteristics of residents. Results: Four thousand eight hundred seventy-four records were retrieved and eventually 47 studies with 151,911 participants were included. The quality scores of most of studies were beyond 4 points (91.49%). The pooled incidence of CHE of Chinese residents in the last two decades was 23.3% (95% CI: 21.1 to 25.6%). The CHE incidence increased from 2000 to 2017, then decreased over time from 2017 to 2020. From 2000 to 2020, the CHE incidence in rural areas was 25.0% (95% CI: 20.9 to 29.1%) compared to urban 20.9% (95% CI: 18.3 to 23.4%); the CHE incidence in eastern, central and western China was 25.0% (95% CI: 19.2 to 30.8%), 25.4% (95% CI: 18.4 to 32.3%), and 23.1% (95% CI: 17.9 to 28.2%), respectively; the CHE incidence was 30.9% (95% CI: 22.4 to 39.5%), 20.3% (95% CI: 17.0 to 23.6%), 19.9% (95% CI: 15.6 to 24.1%), and 23.7% (95% CI: 18.0 to 29.3%) in poverty group, low-income group, middle-income group, and high-income group, respectively. Conclusions: In the past two decade, the incidence of CHE in rural areas is higher than that of urban residents; higher in central areas than in eastern, western and other regions; in poverty households than in low-income, middle-income and high-income regions. Further measures should be taken to reduce the incidence of CHE in susceptible people.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The incidence of catastrophic health expenditure in sub-Saharan Africa was lower than in China in the last decade but higher than in Europe, Asia, and South America, irrespective of the definition used.
“The incidence of catastrophic health expenditure we found in sub-Saharan Africa was lower than in China in the last decade,139 but higher than in Europe,140–142 Asia,134,143,144 and South America,145,146 irrespective of the definition used.”
From Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis (2022) · cites this paper as [139]
The study is a methodological improvement on previous studies because it used several measures of catastrophic health expenditure.
“The study is a methodological improvement on previous studies as we used several measures of catastrophic health expenditure.134,139,143,144”
From Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis (2022) · cites this paper as [139]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A., Clarke, M., Devereaux, P. J., Kleijnen, J., & Moher, D. (2009) · PLoS Medicine · doi:10.1371/journal.pmed.1000100 · Cited by 28,164 · see citing works
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A., Clarke, M., Devereaux, P. J., Kleijnen, J., & Moher, D. (2009) · Annals of Internal Medicine · doi:10.7326/0003-4819-151-4-200908180-00136 · Cited by 10,349 · see citing works
Household catastrophic health expenditure: a multicountry analysis
Xu, K., EVANS, D. B., Kawabata, K., Zeramdini, R., Klavus, J., & Murray, C. J. L. (2003) · The Lancet · doi:10.1016/s0140-6736(03)13861-5 · Cited by 2,322 · see citing works
Progress on catastrophic health spending in 133 countries: a retrospective observational study
Wagstaff, A., Flores, G., Hsu, J., Smitz, M.-F., Chepynoga, K., Buisman, L. R., van Wilgenburg, K., & Eozenou, P. (2018) · The Lancet Global Health · doi:10.1016/s2214-109x(17)30429-1 · Cited by 1,019 · see citing works
Li, Y., Wu, Q., Xu, L., Legge, D., Hao, Y., Gao, L., Ning, N., & Wan, G. (2012) · Bulletin of the World Health Organization · doi:10.2471/blt.12.102178 · Cited by 419 · see citing works
Public spending on health care: how are different criteria related?
Musgrove, P. (1999) · Health Policy · doi:10.1016/s0168-8510(99)00024-x · Cited by 127 · see citing works
Xu, Y., Gao, J., Zhou, Z., Xue, Q., Yang, J., Luo, H., Li, Y., Lai, S., & Chen, G. (2015) · BMC Health Services Research · doi:10.1186/s12913-015-0892-2 · Cited by 85 · see citing works
Household catastrophic medical expenses in eastern China: determinants and policy implications
Li, X., Shen, J. J., Lü, J., Wang, Y., Sun, M., Li, C., Chang, F., & Mo, H. (2013) · BMC Health Services Research · doi:10.1186/1472-6963-13-506 · Cited by 48 · see citing works
Determinants of catastrophic health expenditures in Iran: a systematic review and meta-analysis
Doshmangir, L., Yousefi, M., Hasanpoor, E., Eshtiagh, B., & Haghparast-Bidgoli, H. (2020) · Cost Effectiveness and Resource Allocation · doi:10.1186/s12962-020-00212-0 · Cited by 46 · see citing works
Zheng, A., Duan, W., Zhang, L., Bao, X., Mao, X., Luo, Z., & Jin, F. (2018) · Cancer Medicine · doi:10.1002/cam4.1590 · Cited by 39 · see citing works
Che, Y. H., Chongsuvivatwong, V., Li, L., Sriplung, H., Wang, Y. Y., You, J., Ma, S., Yan, Y.-J., Zhang, R. Y., Shen, T., et al. (2015) · Public Health · doi:10.1016/j.puhe.2015.03.015 · Cited by 27 · see citing works
Waning, B., Maddix, J., Tripodis, Y., Laing, R. O., Leufkens, H. G. M., & Gokhale, M. (2009) · International Journal for Equity in Health · doi:10.1186/1475-9276-8-43 · Cited by 14 · see citing works
Public spending on health care: how are different criteria related? a second opinion
Jack, W. G. (2000) · Health Policy · doi:10.1016/s0168-8510(00)00093-2 · Cited by 12 · see citing works
HEALTH INVESTMENT AND ECONOMIC OUTPUT IN REGIONAL CHINA
Chen, G., Inder, B., & Hollingsworth, B. P. (2013) · Contemporary Economic Policy · doi:10.1111/coep.12022 · Cited by 12 · see citing works
Lee, H. J., Lee, D. W., Choi, D., Oh, S. S., Kwon, J., & Park, E. (2020) · Cost Effectiveness and Resource Allocation · doi:10.1186/s12962-020-00233-9 · Cited by 11 · see citing works
Zhou, Y.-J., Tang, Y., Zhang, Q., Qiu, P., & Qiang, Z. (2016) · PubMed · Cited by 4 · see citing works
Chen, G. (1997) · Chinese Geographical Science · doi:10.1007/s11769-997-0057-2 · Cited by 2 · see citing works
Flagged first, then by citations
Research works printed but not linked: 16
- [1]Wang H. Review of the 10-year history of medical reform in China and its future prospects. Chinese Hosp Manage. 2019,39(12):1-5.
- [3]Yi J, Yao T, Hongping L, et al. Evolution, current situation and improvement of China's health poverty alleviation policy. Chinese Health Serv Manage. 2019;36(09):668-71.
- [25]Renyou C, Aitian Y, Wenjing Z, et al. Study on the influencing factors of catastrophic health expenditure of rural residents in Tengzhou City. China Health Econ. 2012;31(03):19-21.
- [32]Fang Y, Deng A, Yao F, et al. Analysis of the incidence of poverty caused by disease in rural families with maternal deaths. China Health Econ. 2013;12:24–6.
- [35]Baoli S, Cong S. Research on access to health services and equity of medical burden for low-income farmers. Soft Sci Health. 2014;05:18–21.
- [36]Xu X, Jing L, Shiping F, et al. Analysis of catastrophic health expenditure status and influencing factors of stroke patients in northern Guangdong. Soft Sci Health. 2014;28(08):491-4.
- [37]Yi Y, Hui Z, Wang Y, et al. Research on the influencing factors of catastrophic health expenditure in rural households in Weishan County, Dali prefecture. Soft Sci Health. 2014;28(4):205–7.
- [40]Gao M, Yang J, Hong Y, et al. Disastrous health expenditure of rural households in Hubei Province and its influencing factors. China Health Stat. 2016;33(06):1008-9+1013.
- [43]Wang H. Discussion on the criteria for defining catastrophic health expenditure in rural households: a case study of Qianxi County, HebeiProvince. Economist. 2016(11):132-3.
- [44]Wang Z, Xiangjun L. Analysis of economic incidences and influencing factors of rural chronically ill families. Med Philosophy. 2016(37):55-7.
- [48]Qi Z, Wei L, Yi L, et al. Analysis of catastrophic health expenditure status of rural residents in Shenyang and its influencing factors. China Public Health. 2016;3:306–9 4 pages in total.
- [49]Yujin Z, Yuxin T, Qun Z, et al. Research on disastrous health expenditure and its influencing factors of rural households in Zigong City, Sichuan Province before and after new rural cooperative medical care compensation. J Sichuan Univ. 2016;47:771.
- [50]Zengyi F. Analysis of disastrous health expenditure of households in a City in Western Hubei Province and its influencing factors. Med Soc. 2017;30(04):52-5.
- [53]Xiangrong L, Rong T. Research on the status and influencing factors of disastrous health expenditure of rural households in Yinchuan City. China Prim Health Care. 2017;31(007):1-3.
- [56]Hongbo D, Wu Z. A study on the poverty of the elderly in Hebei Province——based on a field survey of 14 counties in Hebei Province. J Hebei Univ (Philosophy and Social Sciences Edition). 2018;43(1):112–9.
- [57]Jingjing H, Le C, Xiao L, Wenlong C, Wang G, Lu S. Status of diabetes incidence and disease economic incidence in rural elderly in Midu County, Yunnan Province. China Public Health. 2019;35(11):1461–4.
Cited by
Sorted by citations
Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis
Eze, P., Osaheni Lawani, L., Justina Agu, U., & Acharya, Y. (2022) · Bulletin of the World Health Organization · doi:10.2471/blt.21.287673 · Cited by 133 · see citing works
Li, Y., Xu, J., Gu, Y., Sun, X., Dong, H., & Chen, C. (2021) · JMIR Public Health and Surveillance · doi:10.2196/33191 · Cited by 45 · see citing works
Xiao, H., Liang, X., Chen, C., & Xie, F. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192114590 · Cited by 18 · see citing works
Xu, X., & Huang, X. (2023) · Risk Management and Healthcare Policy · doi:10.2147/rmhp.s382812 · Cited by 13 · see citing works
Han, J., Tang, R., & Zhang, Z. (2025) · Patient Education and Counseling · doi:10.1016/j.pec.2025.109275 · Cited by 10 · see citing works
The Impact of Multidimensional Health Levels on Rural Poverty: Evidence from Rural China
Chen, X.-Y., Zhou, T., & Wang, D. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19074065 · Cited by 9 · see citing works
Kaso, A. W., Habtamu, A., Haftu, H. K., Agero, G., Jima, G. H., Kaso, T., Hailu, A., Biesma, R. G., & Stekelenburg, J. (2025) · BMC Health Services Research · doi:10.1186/s12913-025-13723-4 · Cited by 7 · see citing works
Liu, Z., Zou, K., Liu, D., Zhang, M., Shi, Y., Chen, Z., Lang, B., Cheng, X. W., Li, H., Zeng, L., et al. (2023) · Frontiers in Pharmacology · doi:10.3389/fphar.2023.1153972 · Cited by 7 · see citing works
Self-citationChen, K., Qiu, J., Wang, W., Hu, Q., Xu, N., & Qiao, H. (2024) · Scientific Reports · doi:10.1038/s41598-024-80628-3 · Cited by 6 · see citing works
Nie, C., & Feng, Y. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2022.1038543 · Cited by 5 · see citing works
Zhang, X., Miao, W., Wu, B., Lai, Y., Jiao, M., Xia, Q., Zhang, C., Tian, W., Song, Z., Shan, L., et al. (2022) · BMC Geriatrics · doi:10.1186/s12877-022-03432-6 · Cited by 4 · see citing works
Morsi, H. M., Akhtar, T. N., Miller, H. D., Balkaya, Ö., Clapsaddle, J., & Clark, H. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1533599 · Cited by 2 · see citing works
Zhou, M.-C., Chen, Z.-X., Fan, K. T., Guo, J., Wang, X., & Ma, S. (2025) · Frontiers in Public Health · doi:10.3389/fpubh.2025.1658120 · Cited by 1 · see citing works
Kołodziej, Ł., Kwiatkowski, S., Gebska, M., Walaszek, I., & Skonieczna‐Żydecka, K. (2024) · Healthcare in Low-resource Settings · doi:10.4081/hls.2024.12432
Yan, Z., Zhou, Z., Deng, Q., Liu, G., Gong, S., & Shen, C. (2024) · Research Square · doi:10.21203/rs.3.rs-5454840/v1
RetractedZhang, L., Tan, S., Wu, X., Pang, H., Yang, M., Xia, M.-M., Luo, X.-L., Huang, Y.-L., & Fu, J. (2025) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2025.103020
Self-citationWang, X., Cai, Z., Lu, Y., Ai, F., & Yao, W. (2025) · Research Square · doi:10.21203/rs.3.rs-8091430/v1
Lin, Z., He, Y., Xu, H.-X., & Xiao, L. (2026) · World Journal of Gastrointestinal Oncology · doi:10.4251/wjgo.v18.i4.113266
Li, Y., & Dong, J. (2026) · Research Square · doi:10.21203/rs.3.rs-9659099/v1
Li, Q., & Huang, X. (2026) · BMC Public Health · doi:10.1186/s12889-026-28620-6
- Authors
- Yuan, Q., Wu, Y., Li, F., Yang, M., Chen, D., & Zou, K.
- Affiliations
- Sichuan University (CN)
- Corresponding author
- Chen, Dandi
- Zou, Kun
- Venue
- BMC Health Services Research
- Published
- 2021-06-24
- Volume
- 21
- Issue
- 1
- Pages
- 600-600
- ISSN
- 1472-6963 (ISSN-L)
- PMC
- PMC8229446
- OpenAlex
- W3173585381
- Cited by
- 19
- References
- 17
- Citations by year
- 2026: 3 · 2025: 6 · 2024: 3 · 2023: 3 · 2022: 3 · 2021: 1
- FWCI
- 0.54
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Health Services Research (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Finance › Healthcare Systems and Reforms
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Economic and Financial Impacts of Cancer
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Keywords
- catastrophic health expenditure, economic status, China healthcare reform, urban-rural differences, regional disparities, household income, health equity, health care costs, incidence trends
- MeSH terms
- Economic Status, Catastrophic Illness, China, Health Expenditures, Humans, Socioeconomic Factors, Health Care Reform
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
