Multifaceted efforts of governments, medical institutions, and financial organizations contribute to reducing the health inequality caused by economic differences

Severe challenge of public health equality in China

Due to the lack of timely and sufficient therapeutic measures, economically disadvantaged patients are likely to have greater losses in life expectancy. Unfortunately, a significant portion of public health funding is consumed by middle- and high-income populations rather than low-income groups. A harsh reality is that although the total annual medical insurance expenditure in China is up to 2.44 trillion-yuan, low-income populations spend less than one-third of the total amount. The health care spending per capita in rural populations is only one-half of the urban population (27,007 vs. 13,713 yuan). This inequality in healthcare resources due to economic disparities is common in China despite the encouraging improvements in universal health coverage (UHC) across most provinces³. For example, the incidence of unmet outpatient and inpatient needs due to financial constraints were up to 4.68% and 18.69%, respectively⁴.

Multiple factors contribute to the above adverse situation. As one of the most essential factors, economic development has exacerbated the inequitable distribution of healthcare resources⁵. Moreover, the profound influence of economic development on healthcare follows the Kuznets curve theory⁶, which posits that healthcare inequality initially increases and subsequently decreases as per capita income experiences an upsurge, displaying an inverted ‘U’ trajectory. The disparities in life expectancy and disease mortality, especially cancer mortality, resulting from economic inequality are enormous⁷. The life expectancy in Shanghai, the most economically developed area in China, is over 80 years, which is significantly higher than the 72 years in less-developed regions, such as Gansu⁸. The average annual percent change (AAPC) of cervical cancer (CC)-related deaths in rural areas is nearly 2 times higher than urban areas (4.5% vs. 2.9%)⁹, indicating that the urban-rural difference in mortality rates for CC becomes greater over time. Interestingly, the mortality rate of cancer patients in rural areas is sometimes lower than urban areas. The 2022 age-standardized mortality rate (ASMR) for breast cancer in China was higher in urban areas than rural areas (6.36/100,000 vs. 5.78/100,000)¹⁰. Similarly, the ASMR for gallbladder cancer patients in China was also higher in urban areas than rural areas (2.02/100,000 vs. 1.48/100,000)¹¹. These results indicate that cancer mortality is an adverse clinical outcome caused by multifactorial factors and the economic level is not the only determining factor. Given the aging society, governments and institutions in China should actively take steps to address these health inequities.

Optimization of resource allocation and subsidy policy

Addressing the healthcare inequality derived from economic differences is a complex issue that requires stronger collaboration from the government, economic organizations, and healthcare institutions. The government could provide more targeted medical subsidies or insurance to residents in low-income areas, especially for cancer screening and treatment. Since 2003 the rural new cooperative medical scheme (RNCMS) has provided basic medical security for up to 700 million rural residents, which also includes the majority of the impoverished population. Despite the great efforts made by the Chinese government for this initiative, more needs to be done to provide financial protection for the most vulnerable. Fu et al.¹² reported a significant association between the incidence of catastrophic health expenditures (CHEs) and the household income level, with the rate much higher among patients with the lowest income compared to patients with the highest income level (88.2% vs. 54.1%). The CHE in patients with RNCMS health insurance was up to 81.88%, which was clearly higher than patients with basic medical insurance for urban employees (BMIUEs) of 64.38%¹². Additionally, the CHE in patients with the lowest quintile of income is 1.6 times that in patients with the highest quintile of income (88.2% vs. 54.1%)¹². These data indicate that the disease burden faced by the deprived populations in China is significantly higher than the higher income groups, even under the current health insurance policies.

Clearly, the populations with good economic conditions commonly have a better ability to weaken the threat of disease. Good economic conditions have more therapeutic options at the time of illness but economic advantages often facilitate early prevention, early screening, and early treatment for the populations with good economic conditions. Therefore, with the exception of RNCMS, the government can provide additional severe illness or special relief funds for low-income populations to minimize the aforementioned disparity in medical protection. Additionally, when providing special subsidies, it is necessary to fully incorporate the recommendations of medical experts and epidemiologic surveys to more effectively compensate for the efficiency inequity of health insurance policies in protecting different income populations. As an example, for breast and prostate cancer, which have the most pronounced LOLE or high incidence of CHE¹³, the reimbursement ratios or funding amount from health insurance can be appropriately increased.

Promoting health behavior via economic incentive

Whoever started the trouble should end it. Since economic disparity is an important contributor to health inequality, resolving this issue through economic means may be more straightforward than single policy support. For example, the U.S. Food & Drug Administration (FDA) has contributed to the development of drugs that have lower commercial value through a series of incentive policies, such as fast-track designation, break-through designation, and accelerated approval¹⁴, which has far-reaching implications for patients with rare diseases.

Low-income populations commonly adopt a relatively passive attitude towards disease screening and management because therapeutic interventions may reduce the working time, thereby exacerbating their income constraints¹⁵. Available evidence confirmed that the survival rate is significantly different between non-attenders and screen-detected women from the most deprived areas¹⁶. Therefore, appropriately implementing economic incentives may encourage deprived residents to complete health assessments and screening or early detection, thereby leading to a risk reduction of the longevity loss in these populations. A study from France revealed that a financial incentive of 20 euros will effectively facilitate the detection rates of HPV infections among women in deprived areas¹⁷. The latter is the most critical screening approach for CC because nearly 100% of CC cases are caused by HPV infection. Clearly, reasonable economic incentives favor impoverished populations making the decisions beneficial to disease intervention.

Proactive financial navigation intervention

Financial hardship is a well-known struggle faced by patients, especially cancer patients. Regretfully, few medical centers provide the professionally financial assistance, including medical costs, assets management, debts, and household expenses of counseled families¹⁸. Addressing this easily overlooked issue, some researchers have developed community organizations to provide financial literacy resources and financial counseling to cancer patients and caregivers, such as the Consumer Education and Training Services (CENTS) and Patient Advocate Foundation (PAF)¹⁹. The final results strongly corroborate the notion that proactive financial navigation has a positive impact on financial distress and quality of life for cancer patients, especially for households with an annual income of <50,000 USD¹⁹. In view of this finding, proactive financial consulting is a pivotal complement to gap the health inequality caused by economic factors.

Conclusions

A recent study published in Cancer Biology & Medicine quantified the unfavorable effects of socioeconomic status on the LOLE of cancer patients². Given the severe situation of public health inequality induced by economic differences in China, several measures should be highlighted, including optimizing the resource allocation and subsidy policy, promoting health behavior via economic incentives, and powering the proactive financial navigation intervention. We believe that the efforts of governments, medical centers, and financial institutions will ultimately reduce health inequalities caused by poverty.

Author contributions

Conceived and designed the analysis: Jiancang Ma.

Wrote the paper: Fangshi Xu, Hangyu Fu.