Poverty is a global issue that requires hard work of all governments. The relationship between poverty and health has been well documented [1, 2]. To break vicious cycle between poverty and poor health, healthcare system becomes the fundamental part of protecting households from disease-associated financial catastrophe [3]. However, needed healthcare remains unavailable to millions of people owing to economic status, especially in poor and vulnerable groups [4, 5]. According to statistics from WHO, nearly 100 million people were pushed into poverty due to high out-of-pocket payments (OOP) [6].
OOP refer to the payments paid by individuals directly to health care providers [7]. Empirical evidence indicated that OOP was the most inefficient and inequitable means of healthcare financing, and prevented patients from seeking medical services [3]. CHE occurs when OOP consumed a huge part of a household’s available income, thus forcing the household into risk of impoverishment [8, 9]. Even modest healthcare bills could compel households into facing CHE, when health financing mechanisms are unavailable or deficient. The possibility of CHE leading to household impoverishment raises equity concerns [10].
Different approaches were used to measure CHE: OOP account for ≥ 10% of total household expenditures [11–13], and OOP account for ≥ 40% of non-food household expenditures, which is proposed by WHO [14, 15]. Previous studies suggested that a wide range of household characteristics associated with CHE. Logically, income is the most significant factor contributing to CHE inequality [16, 17]. Availability of health insurance can help reduce CHE incidence [11, 18]. On the contrary, households with older adults ≥ 65, children ≤ 5, chronically ill members, disabled members [19], and those who use inpatient healthcare services are facing higher risk of CHE [20]. Compared to households with more members, households with fewer people are more likely to occur CHE [21]. There are also some other factors associating with CHE: gender, education level of household head, and healthcare service utilization [22].
On a global scale, the proportion of OOP in the world's population exceeding 10% of total household expenditure increased from 9.4% in 2000 to 12.7% in 2015 [23]. Previous studies indicated that CHE incidence (non-food threshold of 40%) in France in 2011, Sweden in 2012, Germany in 2013 and Britain in 2014 was only1.9%, 1.8%, 2.4% and 1.4%, respectively, which were much lower than average level of 3% in OECD countries [24]. But for developing and underdeveloped countries, the situation is not so optimistic owing to lack of risk-share mechanism. In 2008, 11.8% of Iran's population incurred CHE and was compelled into poverty [25]. China is no exception, previous study showed CHE incidence in 2015 was 16.5%, and the households that actually incurred CHE spent 64% of their non-food consumption expenditure on medical expenses [26].
Therefore, to protect rural residents from large medical expenses, China has established New Rural Cooperative Medical Insurance (NRCMI) in 2003.In 2016, to further improve medical insurance level for rural residents, Chinese government decided to set up Urban and Rural Residents' Medical Insurance (URRMI) combined by both NRCMI and Urban Resident Basic Medical Insurance (URBMI).Despite realization of full coverage, the medical economy burden of Chinese residents was still high with OOP accounting for 28.61% in 2018[26].There was evidence showing that households insured by NRCMI almost had the same levels of CHE as those without any type of insurance[27–29].Moreover, several Chinese studies also reported that compare to urban households, rural households were still facing higher CHE risk, which associated with the fairness of healthcare services [30–32].
Numerous studies have conducted CHE studies on a specific country rather than vulnerable groups in the country. Owing to economic status, these vulnerable groups are still prevented from seeking needed and timely healthcare, and medical insurance systems haven’t played an effective role in protecting them from occurring CHE [33]. However, few studies have examined incidence and determinant factors of CHE among rural impoverished households in China. As China has gradually realized the universal coverage of basic medical insurance system over the past three decades, relieving economy burden of rural poor residents’ healthcare services and reducing inequality in medical insurance should gradually become the focus of new reform. Therefore, based on 2018 CHARLS data, this study aimed to analyze CHE incidence and intensity among rural poor households, and its socioeconomic inequality. Furthermore, our findings may contribute to improvement and adjustment of URRMI, thereby further relieve economy burden of healthcare and promote equity of healthcare system and services.