Unmet healthcare need is a key indicator to assess the operation of a country’s health service system, and any barriers of access to healthcare should be identified and then eliminated . By analyzing the unmet inpatient service among the migrants is vital to develop targeting measures, so as to better meet the health services needs of the migrants. Using the National Internal Migrant Population Dynamic Monitoring Survey dataset, the current study explored the relationship between individual’s SES and unmet inpatient service among the internal migrants in China, and found that individual-level SES indicators including economic status, employment status and educational attainment are significantly associated with unmet inpatient service needs among the migrants.
Our study indicated that economic status of internal migrants was a key barrier to accessing inpatient service. Compared with those in the low-economic status group, internal migrants with higher economic status were more likely to use inpatient service when they had an inpatient service need, which was consistent with the top reason (economic hardship, 36.29%) for unmet inpatient service needs among internal migrant. Previous studies have shown that the risk of unmet inpatient service of the poor people was significantly higher than that of non-poor people, both in the permanent residents and the migrants[4, 25]. There are several possible reasons for this finding. First, migrants with higher economic status in China have higher payment capacity, and hence, they were more likely to use inpatient services when in need. Second, most of those with low economic status were those rural-to-urban migrants. The primary goal for the migration in such population was in search of better income in urban areas. Thus, they tended to focus on their economic conditions only, and usually ignore their own health. Even they had inpatient need, going to hospital would cause substantial economic losses for them. Despite the nearly universal medical insurance coverage in China, economic status remains the dominant obstacle in the use of healthcare services[26–28], including outpatient and inpatient services, and contributed to inequity in general health care utilization[29–31]. This phenomenon is even more serious among the internal migrants. Therefore, policy makers should pay more attention to migrants with low economic status, and develop pro-poor health insurance scheme to meet the inpatient service need among the migrants.
This study also found that low educational attainment was associated with unmet inpatient service need among internal migrants, which was consistent with other studies[15, 32–34]. One possible explanation was that the internal migrants with higher education usually had more knowledge and awareness about the importance of inpatient service use, and thus tended to use inpatient services when they have a need. Accordingly, future interventions might consider using health education focused on migrants with low level of education. It is worth mentioning that popular and easy ways should be conducted to intervene for migrants with low educational attainment and improve their use of inpatient service when in need. In addition, a better form of health education on migrants is peer education. Those low education migrants with a similar age, gender and economic status can have a common topic of discussion, and thus share information, so as to amplify the effect of “peer effect”.
To our surprise, the unemployed internal migrants were more likely to use inpatient service when in needs than the employed migrants, which was inconsistent with previous studies15. One possible explanation for this finding was the ‘healthy worker effect’. This effect has been demonstrated in many migrant populations[35, 36]. First, employed migrants tended to be in better health status than the general population due to the exclusion of unhealthy migrants from employment. They often have better self-perceived health outcomes than those unemployed migrants, hence they may choose to ignore inpatient service. Second, under the pressures of working, employed migrants were more inclined to ignore the health problems, which is consistent with the second reason (Feeling unnecessary, 34.43%) for unmet inpatient service need among internal migrant. The employed migrants had less free time than those unemployed migrants. Migrants who had a job need to pay the price of absenteeism and sick leave to use the inpatient service. Last but not the least, some unemployed migrants moved to the cities only to seek better health services rather than to seek jobs. These reasons may explain the lower possibility to use inpatient service when they in need among employed migrants.
The major contribution of this study was that we sought to identify the relationship between individual’s SES and unmet inpatient service among internal migrants. Although previous studies have shown that high-SES is a protective factor in using public health service among the migrants[9, 15, 17, 19, 38, 39], but few studies have explored the association between SES and unmet inpatient services among internal migrants in China. However, this study also had several limitations. First, it was a cross-sectional study, could only be used to explore associations between SES and inpatient service utilization among migrants. The relationships that we inferred cannot be interpreted as causal in nature. Second, the use of hospitalization services and doctor's diagnostic information of the internal migrants were both self-reported, therefore, recall bias might exist. Final, inpatient service utilization based on health needs was also determined by the accessibility of health services in terms of geography, cultural and administrative barriers in addition to socioeconomic status. It was necessary to explore more associated factors in the future.