Policy stringency during the COVID-19 pandemic and healthcare services utilization in China: An interrupted time-series analysis

by Hong Xiao, Guanin Bai, Fang Liu, Yuechong Cui, Joseph M. Unger

Background

The COVID-19 pandemic has profoundly impacted healthcare systems worldwide, with China presenting a unique case. As the first country to report COVID-19 cases and the last to lift its stringent Zero-COVID policy, China presents a distinctive context for understanding the long-term effects of the pandemic on healthcare utilization. This study provides a comprehensive analysis of healthcare utilization trends in China over more than four years of the pandemic, focusing on how different phases, including the Zero-COVID policy and its cessation.

Methods and findings

We conducted an interrupted time-series analysis of monthly healthcare utilization data from January 2015 to April 2024, including outpatient visits and inpatient discharges, across Mainland China, controlling for underlying secular trends and patterns. Hospital-based healthcare utilization data were sourced from the National Health Commission of China, and daily Policy Stringency Indices (higher values indicating stricter control policies) were obtained from Oxford’s COVID-19 Government Response Tracker. We modeled changes in healthcare utilization using negative binomial regression, comparing actual outcomes with counterfactual estimates based on pre-COVID trends. We assessed healthcare utilization during key pandemic phases, including the post-Zero-COVID period. Healthcare utilization in China experienced substantial declines during the pandemic, with an estimated reduction of 1.21 billion (7%) outpatient visits and 140.9 million (13%) inpatient discharges compared to expected levels from January 2020 to April 2024. The most pronounced declines occurred during the initial pandemic waves and coincided with periods of stringent Zero-COVID measures. Negative associations between the Policy Stringency Index and healthcare utilizations were observed. Before the lifting of the Zero-COVID policy, a 10-point increase in the Policy Stringency Index was associated with a 7.2 percentage point decrease in outpatient visits and a 6.2 percentage point decrease in hospitalizations. Although healthcare utilization gradually rebounded following the cessation of the Zero-COVID policy, as of April 2024, utilization remained below expected levels in 20 (65%) of the 31 regions for outpatient visits and in 23 (74%) for inpatient discharges. Regional disparities were evident, with more developed areas, such as Shanghai and Beijing, experiencing the largest absolute reductions after adjusting for population size. In Shanghai, outpatient visits declined by 4,997 and hospitalizations by 241 per 1,000 people. In contrast, the largest relative reductions occurred in less developed regions, where outpatient visits dropped by 16% in Guizhou and hospitalizations declined by 27% in Shanxi. Use of aggregated routine health system data limited individual-level analyses, assessment of care quality, and disentangling of causal pathways.

Conclusions

The COVID-19 pandemic and Zero-COVID policies were associated with substantial and enduring disruptions to healthcare utilization in China, characterized by slow recovery and regional disparities in access. These findings underscore the importance of strengthening healthcare systems to enhance resilience and better balance public health interventions with the maintenance of essential healthcare services in anticipation of future public health crises. Continued targeted efforts are needed to address the delayed recovery, particularly in regions with already strained healthcare infrastructure, and to ensure equitable healthcare access across the country.