multidimensional inequalities in health care distribution in provincial china: a case study of henan...

MULTIDIMENSIONAL INEQUALITIES INHEALTH CARE DISTRIBUTION IN PROVINCIALCHINA: A CASE STUDY OF HENAN PROVINCE

YINGRU LI* & YEHUA DENNIS WEI**

*Auburn University, Department of Geology and Geography, Auburn, AL, United States.E-mail: [email protected]**University of Utah, Department of Geography, Salt Lake City, UT, United States.E-mail: [email protected]

Received: June 2012; accepted May 2013

ABSTRACTThis paper analyses multidimensional inequalities in health care distribution for Henan Provincein central China. The paper has two objectives: (1) examining the multi-scale health care inequalityin Henan from two dimensions, urban-rural and core-periphery and (2) revealing the spatialeffects of China’s multiple transitions, provincial development strategies, and local economicdevelopment on health care distribution. The authors used geographic information systems-basedspatial statistical methods to detect the spatial-temporal variation of health care distribution, andapplied geographically weighted regression to reveal the effects of multiple transitions on thehealth care sector. The results illustrate that urban-rural and core-periphery gaps in Henan are stillsignificant even though health care reforms and recent provincial policies have improved theaccess of rural and peripheral areas to health care. Health care inequality is sensitive to geographi-cal scale and clustering, and spatial patterns of health care are shaped by the interwoven forces atnational, provincial, and local scales.

Key words: Regional inequality, health care, Henan Province, China, GWR

INTRODUCTION

After 30 years of dramatic economic growth,China surpassed Japan and became the world’ssecond largest economy in 2010. However,besides sheer economic performance, the well-being of the population is also an importantmeasure of human development (Li 2012).China’s reform has been an uneven process,with various layers to the transition. The phe-nomenal economic growth and profoundsocial change have been accompanied byserious social problems. The economic devel-opment and transitions have generated nega-tive ramifications, and social conflicts have

intensified in recent years. In particular,regional inequality has caused increasing con-cerns among both policy-makers and thepublic, since it reflects unequal opportunitiesamong regions and may threaten national unityand social stability (Wei 2000). In recent years,the Chinese people have become more dissat-isfied with unevenness in medical care, educa-tion, and other measures of welfare. For theChinese government, promoting social equity,especially reducing coast-interior and urban-rural disparities, is one of the core themes ofthe 12th Five Year Plan (2011–2015) in China.

Health care has become the leading concernof the Chinese people due to rising costs to

Tijdschrift voor Economische en Sociale Geografie – 2014, DOI:10.1111/tesg.12049, Vol. 105, No. 1, pp. 91–106.© 2013 Royal Dutch Geographical Society KNAG

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mailto:[email protected]

patients and unequal access to medical care(Guo 2003; Hu et al. 2008; Wagstaff & Lindelow2008; Yip & Hsiao 2009; Li & Wei 2010a). Sincethe health care reforms of 1985, China’s previ-ous far-reaching health care system has beenreplaced by the current approach. In urbanareas, the traditional system provided freehealth care for employees of government-related facilities and organisations. The currentsystem uses a cost-sharing structure in whichthe patients have to pay a large proportion oftheir own medical costs. Rural populationshave been experiencing more difficulties withmedical care since the reforms. In the early2000s, 79.1 per cent of the total rural popula-tion did not have health insurance and had topay medical costs in full by themselves (WHO2005; Hu 2007). In addition, the central gov-ernment has left the financial burden offunding local health care systems to the localgovernments, which has caused rising inequal-ity in urban-rural and urban-urban health care(Akin et al. 2005; Li et al. 2006, Li & Wei 2010a).

Regional inequality in China has long been akey subject of academic inquiry (e.g. Fan 1995;Kanbur & Zhang 1999; Wei 1999). The unevenquality of and accessibility to basic socialresources, is one of the key reasons causing thepolarised society (Keidel 2009). More recently,scholars have attempted to describe andexplain various measures of social inequality inChina, for example, education (Cao 2008; Qianand Smyth 2008; Wu 2008), gender (Cai & Wu2006; Shu et al. 2007), and health care (Zhao2006; Chou & Wang 2009). Nonetheless, theliterature has overwhelmingly linked regionalinequality to economy and neglected the influ-ence of social inequality as both a cause and aconsequence of regional economic disparities(Cao 2008). Despite the fact that this problemmerits deep investigation, the analysis ofChina’s health care disparity is relativelylimited.

In China, the health care system has alwaysbeen an appendage of the economic systemsand health care disparity has been demon-strated as one of the consequences of economicinequality and socio-economic transitions (Li &Wei 2010a). In this study, health care inequalityis examined based on regional developmenttheories and China’s development mecha-nisms. This paper analyses the changing

pattern of health care inequality in a rarelystudied inland province, Henan, and furtherexamines the influences of China’s transitionsand provincial development strategies on itshealth care system. The next two sectionsoutline literature and the analytical framework,followed by the methodology of this research.Then we present and explain results and con-clude with major findings.

LITERATURE REVIEW

There have been intense theoretical debates onregional inequality between convergence anddivergence schools since the 1950s. There arealso other theories that attempt to explainmechanisms of regional development. Forexample, growth pole theory (Perroux 1955)points out that the locations where entrepre-neurial innovation and ‘propulsive industries’are clustered, serve as the engines for innova-tion and regional growth. Since the late 1980sand early 1990s, the new convergence and neweconomic geography (NEG) theories havecome to the fore. The new convergence theoryholds that convergence occurs because of thetendency of poorer regions to grow morerapidly than richer ones (Barro & Sala-i-Martin1992, 1995). Krugman and Venables (1995)developed a core-periphery model for under-standing how the centripetal forces pull econ-omic activity together and the centrifugalforces push it apart, and how these twoforces shape the geographical structure of aneconomy under globalisation.

Despite differences among the above theo-ries, they have a common limitation in that theydo not take geographic scale and space intoserious consideration. More recently, scholarshave demonstrated the importance of spatialcomponents on regional inequality in domainsof both economic and social development.Dunford and Smith (2000) pointed out thatEurope was producing complex and differenti-ated mosaics of uneven development withreduced inequality at some scales, and persis-tent or widening inequality at others scales. Wei(1999, 2002) and Wei and Ye (2009) arguedregional inequality in China was layered in amulti-scale manner. Regional differences inmedical service and health status also show dis-tinctive geographic characteristics (Dib et al.

92 YINGRU LI & YEHUA DENNIS WEI

© 2013 Royal Dutch Geographical Society KNAG

2010). Li and Wei (2010a) found that China’shealth care inequality was sensitive to spatialscale and also that finer-scale unevenness wasgreater. According to the 2008 National HealthServices Survey, Sun et al. (2011) comparedpopulation health, measured by the standard-ised EQ-5D instrument, from different spatialdimensions in China. It revealed health dispari-ties among east-central-western regions andbetween urban-rural areas stemming from thegap in socio-economic development. People inmiddle-sized cities had the best health statusdue to the lower stress level and better environ-ment compared to large and small cities.

Regional inequality in China is multi-dimensional, and recent research hasadvanced our understanding of the space andscale of regional inequality, moving beyondthe orthodox black-box approach. Scholarshave identified the typical core-peripheryspatial pattern of China’s regional develop-ment (Zhang & Kanbur 2005; Cao 2010),reflected by two-dimensional measures of soci-etal polarisation, coastal-inland and urban-rural gaps. In the early stages of the economicreform, the central government was prone todevelop the coastal region and encouragedthis region to ‘get rich quick’ (Wei 1999).Consequently, literature tended to study thecoastal provinces and to explore the inequalitymanifested along the coastal-inland dimension(e.g. Fan 1995; Chen 2010; Li & Wei 2010b).Research has unfolded complex patterns ofintra-provincial inequality and core-peripheralrelationships. The core-periphery gaps havepersisted or even intensified in some provinceslike Jiangsu (Wei et al. 2011) and Guangdong(Lu & Wei 2007; Liao & Wei 2012). Zhejiang ischaracterised by spatial restructuring with newemerging centers (Ye & Wei 2005; Wei & Ye2009). As the intensification of the rural-urbandivide and the shift of central governmentpolicy focus to some of the interior provinces,the urban-rural inequality has graduallyattracted more attention. The urban-rural gapis still prominent even though the governmenthas accelerated the urbanisation process forreducing the difference.

Health care has been a burning topic in bothdeveloped and developing countries; however,the study of China’s health care inequality stillremains limited (Li & Wei 2010a), compared to

the extensive research on economic disparity.Scholars have examined health care inequalityand the underlying factors (e.g. Zhan 2005;Eggleston et al. 2008; Wang et al. 2009; Li &Wei 2010a). Zhang and Kanbur (2005) docu-mented the increasing trend of urban-ruraldisparity and the decreasing trajectory ofinter-provincial inequality in health care. Wanget al. (2009) proposed that the high costs andinequality in health care were caused by inad-equate government investment as well as weaksupervision and administration in the past twodecades. Li and Wei (2010a) have provided amulti-scalar and multi-mechanism investigationand noticed a rising spatial concentration ofhealth care during the reform era. They havealso demonstrated that health care inequalityis a major factor for explaining the linkagebetween health outcomes and economicinequality. These national-level studies outlinethe variations in health care in China; and anin-depth investigation of a specific provincewould provide a new angle to better under-stand China’s social unevenness.

Based on the above review, two areas deservefurther investigation. First, little research exam-ines China’s health care inequality with anemphasis on the urban-rural dimension orsheds light on the inland provinces (e.g.Kanbur & Zhang 1999; Cao 2010), wherelimited exposure to globalisation and strongergovernment intervention may have caused dif-ferent health consequences. Second, we main-tain that local health care distribution has beendetermined by both national transitions andprovincial development strategies. However,research on the influence of interaction andcontradiction between national and provincialpolicies on health care inequality is still lacking.

The objectives of this paper thus include:(1) analysing the spatial-temporal variations ofhealth care inequality in a central agriculture-oriented province, Henan; (2) examining theeffects of China’s multiple transitions, provin-cial policies, and local economic developmenton health care systems; and (3) utilising recentdevelopments in geographic informationsystems (GIS) and spatial statistic methods tofurther the understanding of spatial dimen-sions of health care inequality. This paperbuilds on the ‘multi-scalar’ and ‘multi-mechanism’ framework as well as such regional

HEALTH CARE DISTRIBUTION IN PROVINCIAL CHINA 93


development theories as the core-peripherymodel and growth pole theory.

RESEARCH SETTING ANDANALYTICAL FRAMEWORK

Selection of study area – Henan was selected asthe region for the case study. This classic agri-cultural province of China was the origin ofChinese civilisation and culture. Traditionalculture has a strong hold on the people andconservative thoughts have led to a relativelyslow reform process in this area. Henan is alsoone of the most populous provinces in China,with a population of 99.2 million (7.5% ofChina’s total population) and 167,000 squarekilometres (1.74% of China’s territory) in 2008(Henan Statistical Year Book 2009). The rapidpopulation growth and limited resources havebrought a series of social problems, includinginsufficient medical resources. With the imple-mentation of new provincial developmentstrategies, Henan has experienced incredibleeconomic growth since 2000. In 2008, Henanproduced 1,423.4 billion Chinese Yuan of GDP,ranking 5th in terms of the total GDP and 16thin terms of per capita GDP among the 31 prov-inces of China. The investigation of Henan’shealth care not only provides references forother inland provinces of China, but also con-tributes to the literature in an internationalcontext since Asian countries such as India andIndonesia face similar problems of excessivepopulation growth and health care shortfall(Davies 2012).

Multi-scalar – Henan has 18 prefecture leveland 159 county level administrative units(Figure 1), which have been divided to foureconomic zones based on the geographical andhistorical factors. Among them, ZhongyuanEconomic Zone is the core area. The countylevel administrative units include 108 counties(Xian) and 51 districts (Qu). Districts are mostlyurban areas while rural residents are the major-ity in counties. The health care inequalities areexamined at two geographic scales, prefectureand county; and will be compared between coreand periphery areas as well as among urban andrural areas at both prefecture level and countylevel.

Multi-mechanisms – Henan’s health care distri-bution has been determined by both nationaltransitions and provincial development strate-gies (Figure 2). Since the economic reform in1978, China’s health care sector has beenreshaped by multiple transitions such asdecentralisation, marketisation, globalisation,and urbanisation (Li & Wei 2010a). Throughthe decentralisation process, the central gov-ernment has largely reduced medical expendi-tures and has transferred the financial burdento local governments. The result has been thathealth care levels tend to rely highly on localsocio-economic development. Market reformshave eroded the traditional foundation of thegovernment-run health care system (Zhang &Kanbur 2005). Before the reforms, state-ownedenterprises and government agencies providedsubsidised medical services for employees withtheir own clinics. After the reform, the govern-ment established a new cost-sharing insurancesystem since 1998 which covers about 50 percent of the urban population, and made effortsto reconstruct the New Co-operative MedicalSystem in rural areas since 2003. However, thenew systems have not been completed yet andthe health care sector is still in transition.Globalisation is the most important drivingforce of China’s regional inequality (Li & Wei2010a) and unbalanced distribution of foreigninvestment has caused increasing regionaleconomic inequality, which has further influ-enced health care inequality. Provincial devel-opment strategies have also greatly affected thepattern of healthcare inequality. In the lastdecade, Henan’s provincial government hasimplemented new strategies to encourage theprovince to transform from a traditionalagricultural economy into a more pluralisticeconomy. First, urbanisation has become oneof the driving forces of Henan’s development.The large-scale expansion of urban areas madeit possible to accommodate a great number ofmigrants from rural areas. The percentage ofthe population living in agricultural areasdecreased from 76.8 per cent in 2000 to 64 percent in 2008 (Henan Statistical Year Books1994–2010). Urbanisation is not only a devel-opment strategy of Henan Province, but also animportant force of China’s national transitions.Second, the ‘rise of the Zhongyuan EconomicZone’ (also called Zhongyuan Urban Agglom-



eration) has been listed as a major develop-ment strategy in Henan’s Eleventh Five YearPlan (2006–2010). This economic zone consistsof nine prefecture level cities surrounding thecapital city, Zhengzhou. Following the national

development strategy, the Henan provincialgovernment has aimed to prompt socio-economic growth in the advanced core area asa growth pole, and then to drive the develop-ment of peripheral areas. At the national

Figure 1. Henan Province.

Economic development Health care

Decentralisation

Marketisation

Globalisation

Urbanisation

Capital effect (Growth pole)

National transitions

Provincial strategies

Figure 2. The framework of multi-mechanisms.



level, this strategy is conducive to acceleratingHenan’s growth and to reducing the gapbetween the central and coastal regions.However, within Henan Province, this plantends to exacerbate core-periphery inequality.In summary, the interwoven forces of nationaltransitions and provincial development strate-gies have changed the spatial-temporal patternsof Henan’s health care distribution.

DATA AND METHODOLOGY

Data – Data acquired in this paper includessocio-economic and health care data as well asGIS shapefiles. The Henan Statistical YearBooks and China Data Online (http://chinadataonline.org) provide prefecture levelsocio-economic and health care data from1993 to 2008 and county level data from 1997 to2008. GIS shapefiles have been downloadedfrom the China Data Center website (http://chinadatacenter.org). Three commonly usedmeasurements, numbers of hospital beds,licensed doctors, and Grade A hospitals areused to reflect health care quantity and qualityrespectively. Competent doctors and high per-forming hospitals are two of the crucial compo-nents of health care systems (OECD 2010).In China, licensed doctors are high-qualitymedical professionals who have passed throughmedical education, initial training, and peer-review programmes. According to HospitalGrading and Management Standard, issued byMinistry of Health of China, Grade A hospitalsare the highest-quality hospitals in terms ofmedical service and management, medicalquality and safety, and education and researchcapacity.

Following the rational of previous studies(e.g. Li & Wei 2010a), hospital beds per 10,000

persons, is selected as the dependent variableto indicate health care levels in regressionmodels (Table 1). The independent variablesindicating national transitions, provincial strat-egies, and economic development include:GDP per capita (GDPPC, economic develop-ment), local budget expenditure (FINEXP,decentralisation), the percentage of employeesin non-state-owned enterprises (NONSOE,marketisation), foreign direct investment (FDI,globalisation), the percentage of urban popu-lation (URBANISATION, urbanisation), anddistance to Zhengzhou (DISTANCE, growthpole effects).

Methods – Coefficient of variation (hereafterCV), a popular measurement of inequality, hasbeen used to examine the temporal variation ofhealth care inequality. This statistical method isdefined as the ratio of the standard deviation tothe mean. We also used the Getis-Ord Gi* sta-tistic to detect spatial agglomeration amongcounties because it is a useful method tomeasure the spatial concentration of featureswith high values or low values. The degree ofclustering is determined by the differencebetween the statistic’s expectation and the pro-portion of the summed variable within a spe-cific distance from the original weighted pointto the entire summed variable.

The mechanisms behind economic andsocial inequality are examined by geographi-cally weighted regression (GWR). GWR hasbeen developed to deal with non-stationarydata by allowing regression model parametersto change over space (Fotheringham et al.2001, 2002). A regression model is calibratedlocally through a spatial kernel function. Gen-erally two types of spatial kernel functions arepresent in the literature, fixed or adaptive

Table 1. Dependent and independent variables.

Class Type Variable

Dependent variable Health care level Hospital beds/10,000 personsIndependent variable Globalisation FDI (County with FDI = 1; County without FDI = 0)

Marketisation Percentage of employees in non-state-owned enterprisesDecentralisation Per capita local budget expenditureUrbanisation Percentage of urban populationCapital effect Distance to the capital, Zhengzhou CityEconomic level GDP per capita



http://chinadataonline.org

http://chinadataonline.org

http://chinadatacenter.org

http://chinadatacenter.org

spatial kernel functions (Yu 2006). We chosethe adaptive spatial kernel function in thisstudy because it is capable of adjusting thekernel sizes based on the density of the data byadopting larger bandwidths where the data aresparse and smaller ones where the data aredense. A nearest neighbour method is used toproduce the adaptive spatial kernels throughminimising the goodness-of-fit statistics,namely the Akaike information criterion (AIC)(Hurvich et al. 1998; Fotheringham et al. 2002;Yu 2006). We used the spatial statistics tool inArcGIS 9.3 (Esri, Redlands, CA) to conductGWR analysis.

According to the recent applications of GWRanalysis to China’s economic and social devel-opment (Yu & Wei 2003; Yu 2006; Wei & Ye2009; Li & Wei 2010a, b), the regression modelis specified to examine how Henan’s healthcare inequality has been shaped during China’sreform and transitions. The dependent vari-able is health care level. Six independent vari-ables include: (1) Foreign direct investment(FDI), which indicates the force of globa-lisation. The more FDI the region has attractedthe more globalised this region is. Since morethan 50 per cent of districts/counties had littleFDI during the study period, we converted FDIto a dummy variable. Those districts/countieshaving FDI are defined as 1 and the others 0.(2) Percentage of employees in non-state-owned enterprises reflects the level of marketi-sation. A lower percentage indicates higherlevels of marketisation. (3) Decentralisation isrepresented by per capita local budget expen-ditures, showing the input from the centralgovernment to the local government. Higherper capita local budget indicates more decen-tralised power from the central to local govern-ment. (4) Urbanisation is represented by thepercentage of the population living in urbanareas. (5) Distance to the capital, ZhengzhouCity, indicates the influence of the growth pole.The areas close to the capital are expected tohave better health care since they benefit morefrom the provincial development strategies.And (6) GDP per capita reflects the economicdevelopment level.

Given the characteristics of GWR, its mostvaluable advantage for explaining China’s mul-tiple transitions is not to distinguish the signifi-cant mechanisms but to reveal the spatially

varying effect of each mechanism on local econ-omic social development. Also it is inappropri-ate to calculate the global p-value of eachcoefficient for the local model because the rela-tionship between a dependent variable and acertain independent variable varies acrossspace (Fotheringham et al. 2002). Namely,there is a unique local regression model ineach spatial unit. Therefore, unlike previousresearch (e.g. Yu 2006; Wei & Ye 2009), wecomputed p-values of each spatial unit for thesignificant variables identified by the globalmodels (ordinary least squares (OLS) models),and then mapped the coefficients with ArcGIS.The spatial units where the coefficient is signifi-cant at the 5 per cent level are highlighted withcrosshatch. The absolute value of coefficientand local p-value illustrate the different influ-ence of the single mechanism in each spatialunit. In a certain spatial unit, the independentvariable has a significant effect on health carelevels if the local p-value is smaller than 0.05.Furthermore, a positive coefficient indicates apositive influence while a negative one reflectsnegative effects on health care level in thisspatial unit.

SPATIAL-TEMPORAL VARIATION OFHEALTH CARE INEQUALITY

Henan’s health care sector has been reshapedwith the advent of health care reforms, nationalsocio-economic transitions, and provincialdevelopment strategies. By the end of 2009,Henan had 435,000 health care professionalsand 302,000 hospital beds; and the assets of thehealth care sector reached 58.5 billion Yuan(Wang & Chen 2010). By 2007, 157 countieshad implemented the New Co-operativeMedical System, covering 92.06 per cent ofrural residents (Wang & Chen 2010). However,health care is still one of the most difficultproblems in the daily lives of residents, due tothe high medical costs and the uneven distribu-tion of health care.

Table 2 presents the results of CVs of hospitalbeds/10,000 persons and of the absolutenumbers of hospital beds at prefecture andcounty level administrative units from 1993 to2008. CVs of hospital beds/10,000 personsincreased slightly from 0.3 in 1993 to 0.33 in2008 at the prefecture level; while it decreased



from 0.89 in 1997 to 0.68 in 2008 at the countylevel. After dividing the county level units intorural counties and urban districts, we foundthat the inequalities among rural counties andurban districts both declined. Apparently, thehuge disparity in hospital beds/10,000 personsamong all county level units was mainly causedby urban-rural (districts and counties) differ-ences. The health care inequalities weregreater when measured by absolute numbers ofhospital beds. CVs increased at both prefecture(0.42 to 0.53) and county levels (1.2 to 1.32).Unlike the relative terms, the CVs of the abso-lute numbers of hospital beds among urbandistricts (0.76 to 0.86) were much higher thanthose between rural counties (0.36 to 0.35),reflecting the core-periphery inequality inhealth care levels. The most advanced hospitalsmostly agglomerate in the urban core areas,especially in the capital. In 2008, ZhengzhouCity had 27,396 hospital beds, accounting forover 10 per cent of the total in Henan Province(Henan Statistical Year Book 2009).

In order to really understand Henan’s healthcare inequality, we further investigated the dis-parity of health care quality, indicated bylicensed doctors/10,000 persons and the abso-lute numbers of licensed doctors (Table 3). Inrelative terms, the CVs increased from 0.36 to0.54 at the prefecture level but reduced sharplyfrom 0.91 to 0.67 at the county level units. Theinequalities among urban districts (0.52 to0.42) and between rural counties (0.39 to0.31) both decreased. In absolute terms, CVsincreased at the prefecture level (0.44 to0.51) but slightly decreased at the county level(1.29 to 1.27). In general, health care qualityand quantity displayed similar inequalitypatterns.

These results reflect four findings of Henan’shealth care inequality. First, Henan’s healthcare inequality is sensitive to the spatial scaleand the finer scale disparity (county level) islarger, consistent with the national pattern (Li& Wei 2010a). Second, health care facilities andprofessionals are highly concentrated in the

Table 2. Coefficient of variation (CV) of health care quantity (hospital beds/10,000 persons and numbers of hospital beds)of Henan Province.

Hospital beds/1,000 persons 1993 1997 2000 2005 2008

Beds/ 10,000 persons Prefecture cities (18) 0.3 0.3 0.32 0.33 0.33All county-level administrative units (159) N/A 0.89 0.89 0.8 0.68Counties w/o Districts (108) N/A 0.62 0.61 0.53 0.46Districts (51) N/A 0.35 0.34 0.34 0.33

Number of Beds Prefecture cities (18) 0.42 0.47 0.48 0.51 0.53All county-level administrative units (159) N/A 1.2 1.25 1.33 1.32Counties w/o Districts (108) N/A 0.36 0.35 0.35 0.35Districts (51) N/A 0.73 0.75 0.79 0.86

Table 3. Coefficient of variation (CV) of health care quality (doctors/10,000 persons and numbers of doctors) of HenanProvince.

Doctors/1,000 persons 1993 1997 2000 2005 2008

Doctors/1,000 persons Prefecture cities (18) 0.36 0.55 0.54 0.55 0.54All county-level administrative units (159) N/A 0.91 0.87 0.73 0.67Counties w/o Districts (108) N/A 0.52 0.48 0.45 0.42Districts (51) N/A 0.39 0.33 0.31 0.31

Number of Doctors Prefecture cities (18) 0.44 0.48 0.48 0.49 0.51All county-level administrative units (159) N/A 1.29 1.22 1.21 1.27Counties w/o Districts (108) N/A 0.89 0.87 0.79 0.80Districts (51) N/A 0.75 0.73 0.75 0.81



urban areas. Hospital beds/10,000 persons inurban districts were over three times that ofthe rural counties (Table 4). Doctors/10,000persons in urban areas were about four timesthat of rural areas (Table 5). The implementa-tion of the New Co-operative Medical Systemand the urbanisation process have equalisedthe urban-rural distribution to some extent,however, the effects are still limited. Third,core-periphery difference is also prominentdue to the polarised provincial developmentstrategy. Hospital beds/10,000 persons in thecore area were about twice of that in the periph-ery area; licensed doctors/10,000 persons inthe core area were almost twice of that in theperipheral area (Table 5).

Fourth, the health care quality has not beenimproved as much as health care facilities(Tables 4 and 5). From 1997 to 2008, doctors/10,000 persons increased slightly from 11.5 to

12.7 in the entire province but decreased from31.9 to 26.4 in the urban areas. In particular,doctors/10,000 persons sharply declined from55.5 to 42.9 in the core-urban areas becauselarge numbers of rural migrants have moved inand shared the resources. These results revealanother problem of Henan’s health care systemand even that of all China. The budget forenhancing health care quality is very limitedcompared to that for improving medical facili-ties. The number of hospital beds in Henanincreased from 189,000 to 268,000; while thedoctors only changed from 106,700 to 119,300from 1997 to 2008 (Henan Statistical YearBooks 1998 2009). In 2005, the total number ofdoctors in China was 1.94 million, 46,600 lessthan in 1997; while medical expendituresincreased 1.7 times during the same period(Zhou 2007). Namely, the number of doctorsdeclined despite a rapid rise in demand.

Hotspot analysis reveals the spatial patternsof Henan’s health care inequalities of hospi-tal beds/10,000 persons in 1997 and 2008(Figure 3). The spatial distributions of healthcare did not vary largely with time. The hotspotswith high health care levels were mostly distrib-uted in the districts of the core area. Nonethe-less, hidden behind the aforementionedstatistics, a more startling picture reveals ahighly concentrated pattern of the mostadvanced health care. Figure 4 displays thespatial distribution of Grade A hospitals (SanjiaYiyuan). Currently there are 35 Grade A hospi-tals located in Henan Province. Among them,30 are concentrated in the core area, 34 arelocated in the urban districts, and 12 are clus-tered in the urban capital area (districts ofZhengzhou). Though the overall inequalitiesof health care quantity and quality in the prov-ince have been reduced, the most advancedmedical care has not been spatially balanced.From a national perspective, 50 per cent of totalnational health expenditures were distributedto urban hospitals and 8 per cent to publichealth institutions (e.g. disease control institu-tions) in 2005; only 7 per cent and 1 per centwere allocated to county hospitals and villageclinics, respectively, although the rural popula-tion accounted for over 60 per cent of the totalpopulation in China (Tian & Ji 2008). Grade Ahospitals have always been the main beneficia-ries from medical investment.

Table 4. The urban-rural and core-periphery gaps ofhealth care quantity (hospital beds/10,000 persons) inHenan Province.

Region Area 1997 2000 2005 2008

All All 20.3 21.0 21.5 25.7District 53.5 58.2 54.3 57.5County 14.0 13.9 14.3 18.0

Core All 28.5 28.3 29.2 34.5District 71.0 73.3 67.6 71.7County 16.9 16.2 17.1 21.6

Periphery All 15.0 16.2 16.4 19.7District 34.1 41.0 39.4 41.4County 12.3 12.6 12.6 15.8

Table 5. The urban-rural and core-periphery gaps ofhealth care quality (doctors/10,000 persons) in HenanProvince.

Region Area 1997 2000 2005 2008

All All 11.54 11.8 11.4 12.7District 31.9 33.7 27.5 26.4County 7.4 7.7 7.6 7.8

Core All 15.0 15.1 14.2 14.5District 55.5 56.6 44.6 42.9County 8.2 8.4 8.3 8.7

Periphery All 8.9 9.3 9.0 9.2District 21.6 24.3 19.9 19.8County 6.8 7.2 7.2 7.3



HEALTH CARE INEQUALITY ANDECONOMIC TRANSITIONS

The results of regression models, includingglobal and local regressions with 1997 and 2008datasets, are reported in Tables 6 and 7. For the

global OLS models, 85 per cent and 81 per centof health care variations can be explained by sixindependent variables, respectively. GDPPCand URBANISATION are significant at the 5per cent level in the 1997 model, and FINEXP,URBANISATION, and DISTANCE are signifi-

Figure 3. Hotspot analysis of hospital beds/10,000 persons of Henan Province in 1997 and 2008.

Figure 4. Spatial distribution of Grade-A hospitals in Henan Provinces, China.



cant in the 2008 model. These significantvariables are mapped in Figures 5 and 6. Theresults reveal four points of the spatial-temporal variation of Henan’s health care.

First, the local regression models show betterexplanation power than the global models.GWR models reflect 94 per cent (R-square =0.94) and 89 per cent (R-square = 0.89) ofhealth care changes in 1997 and 2008, higherthan both OLS models (R-squares: 0.85; 0.81).GWR models generate significantly lowervalues of AIC and sum of residual squares(SRS), which also demonstrate the better fitand accuracy of the local models. Apparently,Henan’s health care inequality is sensitive tospatial autocorrelation and clustering.

Second, the local economy was the determi-nant factor for shaping health care patternsduring the early stages of reform (Figure 6).GDPPC, indicating the economic develop-ment, was significant in about 2/3 of countylevel units in 1997. It forms a huge positivecluster covering the central, southern, north-eastern, and northwestern parts of the prov-

ince. The health care levels of most spatial unitswere in accord with local economicdevelopment.

The influence of urbanisation (URBANISA-TION) expressed more complex spatial varia-tions. Urbanisation was positively associatedwith health care levels in the northeastern,eastern, and southern areas where the urbanareas had better medical care in 1997. However,an opposite trend was shown in the central corearea,where thespatialunitswithahigherdegreeof urbanisation had lower health care levelsinstead. There are several famous rural countieslocated in this area, which generated more percapita wealth than urban districts. Health carelevels have consequently improved due to theirmaterial affluence and the strong financialsupport their governments provide for healthcare. Based on the literature and above analysis,we believe that the decisive factors in levels ofhealth included not only urbanisation but alsolocal economic development.

Third, the government intervention hasbecome a stronger factor in the health care

Table 6. Global OLS regression results.

1997 2008

Dependent variable Health care Dependent variable Health care

Independent variable Coefficient P-value VIF Independent variable Coefficient P-value VIF

Intercept 2.79 0.23 N/A Intercept 7.88 <0.01 N/AFDIPC –3.03 0.41 2.90 FDIPC 4.41 0.04 2.01NONSOE 11.49 0.12 1.28 NONSOE –3.63 0.51 1.29FINEXP 0.00 0.17 2.04 FINEXP 0.01 <0.001 4.39URBANISATION 78.64 <0.001 5.27 URBANISATION 31.45 <0.001 2.92DISTANCE 0.00 0.13 1.22 DISTANCE 0.00 <0.01 1.24GDPPC 0.00 0.05 2.32 GDPPC 0.00 0.27 3.12

Table 7. Comparison between OLS and GWR models.

1997 2008

OLS GWR OLS GWR

Multiple R-squared 0.85 0.94 0.81 0.89Adjusted R-squared 0.84 0.92 0.80 0.86AIC 905 856 909 883Residual Squares 7,191 2,855 7,409 4,302



sector (Figure 6). Local economic develop-ment (GDPPC) was no longer significant tohealth care levels in 2008. Instead, per capitalocal budget expenditures (FINEXP) becamethe determinant force since decentralisationhad been the most important structural changein the health care sector following the econ-omic reforms (Akin et al. 2005). Except inthe northwest area, FINEXP contributed toelevated health care levels in the rest of theprovince. Apparently, the local health caresector became more dependent on medicalinvestment from provincial and prefecturelevel governments.

Urbanisation(URBANISATION)still showeddual effects across space, whereas its spatialpattern completely changed in 2008. On thewestern side of the province, those places withhigher degrees of urbanisation had bettermedical care; while an opposite trend showed ina long strip of the eastern part where localbudget expenditures happened to play a moresubstantial role. The eastern area is mainlycomposed of the less developed agriculturalcounties. The investment from the New Co-operative Medical System greatly improvedhealth care levels in this area. Allocation ofmedical resources by provincial and prefec-ture level governments has influenced therelationship between health care levels andurbanisation in this area.

The capital effect (DISTANCE) turned outto be significant to health care distribution in2008. The distance to Zhengzhou mattered inabout half of the county level units. Amongthem, the counties and districts close to thecapital had better health care. With the impli-cation of the ‘Rise of Zhongyuan EconomicZone’, the growth pole has become influentialto affect the pattern of the social developmentin Henan Province.

Fourth, the government-led pattern is stillthe most significant feature of China’s healthcare system (Zhou 2007). The variable indicat-ing marketisation is not significant in eitherthe 1997 or the 2008 models (Table 6) sincethe public hospitals dominate the health caresector (Li & Wei 2010a). According to China’sMinistry of Health, state-owned and collectivehealth care institutions accounted for 82.8 percent of the hospitals, 95.1 per cent of the hos-pital beds, and 90.4 per cent of the nation’smedical professionals in 2005 (Zhou 2007;Tian & Ji 2008). Furthermore, governmentsstill control China’s medical service, forexample, assigning the directors of publichospitals and institutions, approving the estab-lishment of new hospitals, and evaluatingmedical professionals (Zhou 2007; Li & Wei2010a). This ‘pseudo marketisation’ might bethe crux of problems with China’s health caresystem.

Note : Coefficients are only significant in units highlighted with crosshatch.

Figure 5. Spatial variations of mechanisms in 1997.



CONCLUSION

This paper investigates the spatial-temporalvariations and the underlying mechanisms ofhealth care inequality in provincial China. Itenriches the literature on regional inequa-lity through examining China’s health caresector with the case study of a central province;Henan Province, instead of the more fre-quently studied eastern/coastal provinces.

This research explores health care disparitiesat multiple scales and dimensions, revealingthat Henan’s health care inequality is sensitiveto spatial scale. The disparity in health care at

the county level is much larger than that atthe prefecture level mainly because of thehuge urban-rural inequality (district-county) ingeneral. The distribution of health care hasbeen greatly influenced by health care reformsas well as national and provincial developmentstrategies. Henan’s urban-rural health care dis-parities have slightly decreased with the imple-mentation of the new Co-operative MedicalSystem and the rapid urbanisation process.Core-periphery inequality is still significantbecause the polarised provincial developmentstrategies have not only accelerated the socio-economic development of the core area but also

Note : Coefficients are only significant in units highlighted with crosshatch.

Figure 6. Spatial variations of mechanisms in 2008.



attracted large numbers of migrants to theseareas. The new residents have diluted theadvances made in core areas by sharing wellbe-ing. Health care facilities, doctors, as well as themost advanced hospitals are highly concen-trated in the urban areas, especially in theurban-core areas, even though the overallinequality has been reduced to some extent.This study explores multi-scale health careinequalities from both urban-rural and core-periphery dimensions, and therefore consti-tutes an advance compared to the previousresearch (Zhang & Kanbur 2005; Li & Wei2010a).

This study examines the disparity in provin-cial health care as one of the most importantconsequences of the regional economicinequality. The pattern of Henan’s health careinequality has been determined by China’seconomic transitions, provincial developmentstrategies, and local socio-economic condi-tions. The influence of the local economy onhealth care levels has been gradually weakenedwith government policy intervention. Decen-tralisation and urbanisation have been twomost important forces for shaping the spatialpatterns of health care inequality. Marketi-sation and globalisation have had little effectsince the governments still control China’shealth care system and the public hospitalsdominate the health care sector. The new pro-vincial development strategies have guided theallocation of medical resources within the prov-ince, which has further influenced the spatialdistribution of health care levels. We also foundthat, the association of Henan’s health careinequality and multi-mechanisms was sensitiveto spatial clustering and agglomeration. Themultiple mechanisms displayed various effectsacross space due to the different local condi-tions and the interaction between nationaland provincial development strategies. This is astep forward from the earlier research on thetopic (e.g. Zhao 2006; Li & Wei 2010a), whichdid not examine the spatial variation of therelationship.

These findings have both theoretical andpolicy implications. The results demonstratethat the health care inequality of provincialChina can be better explained by combiningthe analytical framework of ‘multi-scalar’ and‘multi-mechanisms’ and such Western theo-

ries as the core periphery model and growthpole theory. The integration of Westerntheory and China’s development mechanismsnot only improves the systematic theoreticalanalysis of China’s health care inequality, butalso makes the Western theories applicable toexplain China’s development. From a policyperspective, this finer-scale research revealsthe contradiction between the developmentstrategies implemented by the central andlocal governments. The provincial develop-ment strategy (the ‘Rise of ZhongyuanEconomic Zone’) has obviously widenedsocio-economic inequality within Henan,although it is conducive to narrowing the gapbetween Henan and other coastal provinces.This result reflects that the governments needto better balance the distribution of capitaland resources at the finer scale. In addition,the shortage of doctors and uneven distribu-tion of medical care have become seriousissues, which also reveal some profoundproblems of China’s health care system,including the inefficient allocation of medicalresources as well as the ‘pseudo marketisation’of China’s health sector. The knowledge ofHenan’s health care can be used as referencesfor China’s inland provinces and even otherAsian countries with similar socio-economiccharacteristics.

In conclusion, this paper has documentedthe patterns of health care inequalities in pro-vincial China, identified the urban-rural andcore-periphery disparities at different spatialscales, and revealed the effects of underliningmechanisms on health care distribution. Thisresearch could be improved by consideringother indicators of health care level such asambulant care as well as the influences ofhealth care inequality on health outcomes.Due to the limitation of current data, first-hand survey may provide more knowledge ofChina’s health care distribution in futurestudy.

Acknowledgement

We would like to acknowledge the funding of theNational Natural Science Foundation of China(41028001) and the CAS/SAFEA International Part-nership Program for Creative Research Teams(70921061).



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