China’s health care use has not fully recovered after Zero-COVID policy, with rural regions lagging most

A PLOS Medicine analysis led by Fred Hutch Cancer Center researchers quantified the enduring impact that China’s health policies during the COVID-19 pandemic had on overall health care utilization. As the first country to report COVID-19 cases and implement infection control measures, and among the last to lift such policies, China’s experience presented a unique opportunity to study the relationship between public health measures and health care access.

Based on publicly available aggregate data from all hospitals in China, the researchers discovered substantial, long-term declines in outpatient clinic visits (7%, or 1.2 billion) and hospitalizations (13%, or 141 million) compared to expected levels from 2020 to 2024 in China. Although China’s stringent public health policy, Dynamic Zero-COVID, was lifted in late 2022, the study found that as of April 2024, outpatient clinic visits did not rebound to expected levels in 65% of China’s regions and hospitalizations remained below expected levels in 74% of the country’s regions.

“This study is part of a broader line of research that examines how COVID-19 pandemic measures affected many aspects of health, from access to cancer clinical trials in the U.S. to access to cancer health care and excess all-cause mortality in China,” said Hong Xiao, Ph.D., staff scientist in the Public Health Sciences Division at Fred Hutch and first author of the study. “Understanding the extent to which COVID-19 policies have shaped health, collectively, provides important guidance on how to improve health systems.”

Regional disparities in access

Xiao and collaborators observed regional disparities in health care utilization, with the most significant and long-term impact observed in China’s rural and less-developed regions. Although urban areas such as Shanghai and Beijing experienced the largest absolute reductions in health care utilization during the COVID-19 pandemic, the largest relative reductions in access were found in less developed regions.

“Similar to the U.S., rural communities in China experienced a disproportionate lack of access to health care associated with the COVID-19 pandemic, especially reduced access to higher-quality and specialized care due to the need to travel long distances,” noted Joseph Unger, Ph.D., a health services researcher and biostatistician at Fred Hutch and study senior author. “This analysis helps to further clarify the durable impact the COVID-19 pandemic had across countries.”

The researchers pointed out that the health care data used in this study was available at the aggregate level and did not include demographic data. Therefore, this study doesn’t provide information about potential disparities across socioeconomic groups or based on social determinants of health.

Policy lessons for the next pandemic

Health care utilization following pandemics and outbreaks has varied globally. After the 2014-2015 Ebola outbreak, health care utilization in Liberia rebounded to expected levels within a year, while in Guinea, recovery was slower. Similarly, after the acute phase of the COVID-19 pandemic, inpatient volumes in Japan recovered more slowly than was observed in California, and in South Korea, health care use rebounded quickly to pre-pandemic levels.

Based on the study findings, the researchers recommended that future preparedness efforts should include surge capacity planning, alternative care delivery models like telemedicine and targeted public communication. Additionally, specific policies should be developed to improve health care access and utilization in regions and local health systems that already experience disparities.

“As we rebuild health systems to be more resilient in the face of future challenges, we clearly need to focus on regions where we already see that health care infrastructure is underdeveloped and health care access is inequitable,” said Xiao. “While this study focused on China’s experience, the lessons are invaluable to health policymakers globally: we must thoughtfully balance public health interventions with essential health care services.”

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Robert Egan

Bachelor’s in mathematical biology, Master’s in creative writing. Well-traveled with unique perspectives on science and language.

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