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Background  The problem of accessibility and affordability of health care is reported to be a major social concern in modern China. It is pronounced in rural households which represent 60% of China's population. There are a few large scale studies which have been conducted into socioeconomic inequalities in health care utilisation for rural populations. Those studies that exist are mainly bivariate analyses. The aim of this study is to examine the relationship between socioeconomic characteristics and health service utilisation among rural counties, using aggregated data from a nationally representative dataset, within a multivariate regression analysis framework.    Methods  Secondary data analysis was conducted on China's National Health Services Survey (NHSS) 2003. Aggregated data on health care utilisation, socioeconomic position, demographic characteristics and health status were used. The samples included 67 rural counties. Multivariate linear regression analyses were performed.    Results  The results of the ecological multivariate analyses showed a positive relationship between private insurance coverage and the use of outpatient care (p-value < 0.05, standardised coefficient = 0.22). Annual income was positively correlated with annual medical expenditure (p-value < 0.01, standardised coefficient = 0.56). A rural county's area socioeconomic stratum, a composite measure frequently used in bivariate studies including the NHSS analysis report, could not explain any association with the use of health care.    Conclusions  This study highlights that richer rural households with a greater ability to pay are more able to use health services in China. The findings suggest that the scope of medical insurance might be restrictive, or the protection provided might be limited, and the health care costs might still be too high. Additional efforts are required to ensure that poorer Chinese rural households are able to utilise health care according to their needs, regardless of their income levels or private insurance coverage. This would require targeted strategies to assist low income families and a broad spectrum of interventions to address the social determinants of health.

Ecological analysis of health care utilisation for China's rural population: association with a rural county's socioeconomic characteristics