Economic status and catastrophic health expenditures in China in the last decade of health reform: a systematic review and meta-analysis

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.