Spatio-temporal Patterns and Determinants of Persistent Catastrophic Health Expenditure in China: Evidence from the China Family Panel Studies

Manci Zhou^1,2Zixuan Chen³Keming Fan¹Jing Guo⁴Xiaohua Wang⁵Shuang Ma^1*

• ¹Beijing University of Chinese Medicine, Beijing, China
• ²Tsinghua University, Beijing, China
• ³Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
• ⁴Peking University, Beijing, China
• ⁵Beijing Normal University, Beijing, China

Background The escalating out-of-pocket medical expenses pose a significant threat to the financial stability of households worldwide. Identifying persistent catastrophic health expenditure (CHE) is imperative for alleviating medical-related economic difficulties. This study comprehensively investigates the spatio-temporal dynamics and key determinants of persistent CHE in China across the 2012–2020 period. Methods This longitudinal quantitative study leveraged data from five waves of the China Family Panel Studies (CFPS), conducted biennially from 2012 to 2020. Variables pertaining to the incidence, depth, and duration of CHE were scrutinized, with covariates informed by the Andersen health service utilization model, including predisposing, enabling, and need factors. Spatio-temporal patterns were analyzed through spatial autocorrelation analysis. Tobit regression was employed to analyze CHE depth, whereas a Generalized Estimating Equation model was used to investigate factors influencing the duration of CHE. Results The analytical sample comprised a balanced panel of 2,544 households, yielding a total of 12,720 observations. Although the incidence of CHE decreased from 16.27% to 13.88%, there was a persistent upward trajectory in the intensity of CHE, which rose from 0.026 in 2012 to 0.069 in 2020. The proportion of households experiencing persistent CHE saw a marked increase, escalating from 0% in 2012 to 14.32% in 2020. Rural households demonstrated a higher incidence of CHE compared to urban households, and significant regional variations in persistent CHE were evident. The spatial clustering of persistent CHE experienced a dynamic transition from aggregation to dispersion and then to a partial recovery during 2012– 2020. Factors such as poor self-assessed health status (OR=1.015, 95% CI 0.011 to 0.194; P <0.05), a greater number of family dependents (OR=1.047, 0.040 to 0.053; P <0.05), the presence of chronic diseases (OR=1.013, 0.006 to 0.021; P <0.05), and hospitalization (OR=1.069, 0.053 to 0.081; P <0.05) were significantly associated with an elevated risk of persistent CHE. Conclusions Financial protection against persistent CHE remains a challenge in China, particularly for rural households, low-income groups, families with chronic diseases, and regions with underdeveloped economies. Policy must prioritize enhancing insurance benefit packages, establishing persistent CHE-linked targeted assistance, and implementing region-specific strategies to address the root causes of health-induced poverty.