Analysis of health service amenable and non-amenable mortality before and since China's expansion of health coverage in 2009

OBJECTIVE To explore early impacts of China's health reforms in 2009 on mortality. METHODS Annual mortality counts were obtained from 161 counties across all 31 provinces of mainland China between 2006 and 2012. We examined time-series of health service amenable mortality counts, including separate analyses for deaths from stroke and ischaemic heart diseases (IHD). Non-amenable mortality counts, including separate models for oesophageal and pancreatic cancers, were also analysed as part of a negative-outcome strategy to provide stronger foundations for falsification. Deaths due to amenable causes were hypothesised to decrease, whereas non-amenable causes of mortality would remain uninfluenced. All analyses were conducted using multilevel negative binomial regression. RESULTS Geographical variation was observed for each mortality indicator, especially for IHD, oesophageal and pancreatic cancers. Negative covariances in all models indicated slight degrees of convergence in these geographic variations over time (but not significantly for deaths from oesophageal and pancreatic cancers). Linear and square functions of time indicated a curvilinear inverted parabolic trend between 2006 and 2012 for stroke and IHD mortality. Reduction in health-service amenable mortality over time was observed, but also for health service non-amenable mortality, including deaths from oesophageal cancer. Pancreatic cancer was found to increase across the study period. In counties where residents had more years of education, mortality from stroke was lower and reducing faster over time. A similar spatiotemporal patterning was observed for deaths from oesophageal cancer, and health service amenable and non-amenable causes. Counties with higher mean education years had higher mortality from IHD and pancreatic cancer, but also larger reductions in mortality were evident in areas with greater years of education. CONCLUSIONS Although there was no clear evidence of an early impact of China's health reform on mortality, this does not rule out potentially important contributions to reducing the burden of disease in the longer term.