Downward Allocation of Primary Healthcare Resources and Rural Household Poverty Vulnerability: Evidence from the Construction of County-based Close-knit Medical Communities in China
AI Shuang, MENG Enhui, NIU Geng
Survey and Research Center for China Household Finance/ Research Institute of Economics and Management, Southwestern University of Finance and Economics
Summary:
Achieving common prosperity for all is a fundamental requirement of Chinese-style modernization. In 2020, China successfully lifted impoverished rural residents living under the current poverty line out of poverty, accomplishing a globally recognized milestone in eliminating absolute poverty. However, consolidating these poverty alleviation achievements remains a long-term and challenging task. Rural low-income households have limited capacity to withstand future uncertainties and remain vulnerable, facing the risk of falling back into poverty. Individual health is the foundation of personal well-being, and public health is the cornerstone of national development. Illness not only directly harms individual health but also reduces labor capacity and income, thereby increasing the likelihood of household poverty. Ensuring the health of rural residents is therefore a critical measure to reduce household poverty vulnerability. Despite the continuous increase in the total supply of medical resources, the problem of their uneven distribution across regions still exists, which restricts the balanced development of basic public health services. How to improve rural healthcare service quality to reduce household poverty vulnerability, prevent large-scale poverty relapse, and sustain income growth among the formerly poor is an urgent policy concern. Against this backdrop, this study systematically examines the impact of healthcare resource decentralization on household poverty vulnerability, offering important insights for consolidating poverty alleviation achievements, advancing comprehensive rural revitalization, and promoting the construction of a modern socialist country. Building on the institutional background and existing literature, this paper develops a theoretical framework linking healthcare resource decentralization to rural household poverty vulnerability. We first verify that the reform of Close-knit Medical Communities (CMCs) improves the supply of primary public healthcare resources. We then exploit the 2019 CMC pilot program as a quasi-natural experiment and employ a difference-in-differences approach, using five waves (2015-2023) of microdata from the China Household Finance Survey (CHFS) to estimate the causal effect of healthcare resource decentralization on rural household poverty vulnerability. The results show that healthcare resource decentralization driven by CMC reform significantly reduces rural household poverty vulnerability, and this finding remains robust across a series of specification checks. In terms of resource provision, CMC reform significantly increases the number of medical personnel in community health stations and clinics, hospitals, and village health centers, thereby improving the supply of primary public healthcare resources. Mechanism analysis indicates that reductions in household health risks, increases in medical insurance participation, and higher reimbursement rates for medical expenditures are key channels through which healthcare resource decentralization lowers rural household poverty vulnerability. Heterogeneity analysis further reveals that the vulnerability-reducing effect of CMC reform is more pronounced among rural households with lower levels of human capital, physical capital, and social capital. Based on these findings, three policy implications follow. First, optimizing the structure of healthcare resource allocation and promoting the sustained downward deployment of high-quality medical resources, which can be achieved through personnel rotation, technical assistance, and equipment sharing, can enhance the service capacity of primary healthcare institutions. Expanding CMC coverage while emphasizing equity and accessibility in resource distribution is essential. Second, deepening health insurance reform by expanding coverage, increasing reimbursement rates for primary care, improving provider payment mechanisms, and enhancing fund efficiency can strengthen households' financial protection. Designing flexible contribution schemes and targeted fiscal subsidies for elderly rural residents would further improve the inclusiveness and fairness of the medical insurance system. Third, improving the quality of primary healthcare services through enhanced training of grassroots medical personnel, upgraded medical facilities, and the promotion of family doctor contract services and preventive health management can reduce health risks at the source and lower the probability that illness translates into poverty vulnerability. The marginal contributions of this study are threefold. First, it examines the impact and mechanisms of healthcare resource decentralization on rural household poverty vulnerability, providing direct evidence on how decentralization reduces vulnerability. Second, it expands health economics research by focusing on how the downward allocation of high-quality medical resources affects rural poverty vulnerability, offering new empirical insights for resource allocation and poverty alleviation. Third, the findings offer practical policy guidance for strengthening county-level medical communities and establishing routine mechanisms to prevent rural households from falling back into poverty, supporting rural revitalization and the pursuit of common prosperity.
艾爽, 孟恩慧, 牛耕. 基层医疗资源下沉与农村家庭贫困脆弱性——来自紧密型医共体建设的证据[J]. 金融研究, 2026, 550(4): 168-186.
AI Shuang, MENG Enhui, NIU Geng. Downward Allocation of Primary Healthcare Resources and Rural Household Poverty Vulnerability: Evidence from the Construction of County-based Close-knit Medical Communities in China. Journal of Financial Research, 2026, 550(4): 168-186.
[1] 程名望、Yanhong Jin、盖庆恩和史清华,2014,《农村减贫:应该更关注教育还是健康?——基于收入增长和差距缩小双重视角的实证》,《经济研究》第11期,第130~144页。 [2] 樊丽明和解垩,2014,《公共转移支付减少了贫困脆弱性吗?》,《经济研究》第8期,第67~78页。 [3] 樊淼、李之淳、杜金芮和孙玉凤,2025,《县域医共体医保总额付费效果研究》,《卫生经济研究》第1期,第48~51页。 [4] 封进、吕思诺和王贞,2022,《医疗资源共享与患者就医选择——对我国医疗联合体建设的政策评估》,《管理世界》第10期,第144~157页。 [5] 高和荣,2017,《健康治理与中国分级诊疗制度》,《公共管理学报》第2期,第139~144页。 [6] 高明、艾美彤和贾若,2021,《家庭金融参与中的信任重建——来自农村社会养老保险的证据》,《经济研究》第8期,第174~191页。 [7] 甘犁、尹志超、贾男、徐舒和马双,2013,《中国家庭资产状况及住房需求分析》,《金融研究》第4期,第1~14页。 [8] 顾昕,2019,《“健康中国”战略中基本卫生保健的治理创新》,《中国社会科学》第12期,第121~138页。 [9] 郭士祺和梁平汉,2014,《社会互动、信息渠道与家庭股市参与——基于2011年中国家庭金融调查的实证研究》,《经济研究》第S1期,第116~131页。 [10] 何欣、黄心波和周宇红,2020,《农村老龄人口居住模式、收入结构与贫困脆弱性》,《中国农村经济》第6期,第126~144页。 [11] 贾男和王赫,2022,《脱贫农户返贫风险防范政策研究》,《经济研究》第10期,第121~137页。 [12] 兰宇和张鹏,2024,《“脱贫不脱政策”何以防止脱贫农户返贫》,《中国农村经济》第5期,第167~184页。 [13] 刘宏和王俊,2012,《中国居民医疗保险购买行为研究——基于商业健康保险的角度》,《经济学(季刊)》第4期,第1525~1548页。 [14] 刘子宁、郑伟、贾若和景鹏,2019,《医疗保险、健康异质性与精准脱贫——基于贫困脆弱性的分析》,《金融研究》第5期,第56~75页。 [15] 任杨玲、沈迟、曹丹和周忠良,2024,《医保按人头付费改革对过度医疗及医疗费用的影响研究——基于我国西部X市Y区基层医疗数据》,《公共管理学报》第1期,第146~160页。 [16] 宋月萍和谭琳,2006,《卫生医疗资源的可及性与农村儿童的健康问题》,《中国人口科学》第6期,第43~48页。 [17] 万广华、刘飞和章元,2014,《资产视角下的贫困脆弱性分解:基于中国农户面板数据的经验分析》,《中国农村经济》第4期,第4~19页。 [18] 王文娟和曹向阳,2016,《增加医疗资源供给能否解决“看病贵”问题?——基于中国省际面板数据的分析》,《管理世界》第6期,第98~106页。 [19] 王永杰,2022,《人力资本、公平感知与农村居民基本医疗保险参与——基于四川农村地区的实证分析》,《西北农林科技大学学报(社会科学版)》第5期,第153~160页。 [20] 徐超和李林木,2017,《城乡低保是否有助于未来减贫——基于贫困脆弱性的实证分析》,《财贸经济》第5期,第5~19页。 [21] 尹志超和张栋浩,2020,《金融普惠、家庭贫困及脆弱性》,《经济学(季刊)》第5期,第153~172页。 [22] 岳崴、王雄和张强,2021,《健康风险、医疗保险与家庭财务脆弱性》,《中国工业经济》第10期,第175~192页。 [23] 张栋浩和尹志超,2018,《金融普惠、风险应对与农村家庭贫困脆弱性》,《中国农村经济》第4期,第54~73页。 [24] 张吉鹏、葛鑫和毛盛志,2021,《家庭住房需求和资产配置——基于包含人力资本和禀赋异质性的生命周期模型》,《经济研究》第7期,第160~177页。 [25] 赵亚雄和王修华,2022,《数字金融、家庭相对收入及脆弱性——兼论多维“鸿沟”的影响》,《金融研究》第10期,第77~97页。 [26] 邹文杰,2014,《医疗卫生服务均等化的减贫效应及门槛特征——基于空间异质性的分析》,《经济学家》第8期,第59~65页。 [27] 朱凤梅、何庆红和王震,2025,《县域医共体建设对医疗服务利用的影响研究——基于某省紧密型县域医共体建设试点的分析》,《管理世界》第10期,第130~153页。 [28] Borgschulte, M. and J. Vogler, 2020. “Did the Aca Medicaid Expansion Save Lives?”,Journal of Health Economics, 72: 102333. [29] Chaudhuri, S., J. Jalan and A. Suryahadi, 2002. “Assessing Household Vulnerability to Poverty from Cross-Sectional Data: A Methodology and Estimates from Indonesia”, discussion paper, Columbia University. [30] Damme, W. V., L. V. Leemput, I. Por, W. Hardeman and B. Meessen, 2004. “Out‐of‐pocket Health Expenditure and Debt in Poor Households: Evidence from Cambodia”,Tropical Medicine & International Health, 9(2), pp.273~280. [31] Doherty, N. A. and H. Schlesinger, 1990. “Rational Insurance Purchasing: Consideration of Contract Nonperformance”,The Quarterly Journal of Economics, 105(1) , pp.243~253. [32] Gennaioli, N., R. La Porta, F. Lopez-De-Silanes and A. Shleifer, 2022. “Trust and Insurance Contracts”,The Review of Financial Studies, 35(12) , pp.5287~5333. [33] Günther, I. and K. Harttgen, 2009. “Estimating Households Vulnerability to Idiosyncratic and Covariate Shocks: A Novel Method Applied in Madagascar”,World Development, 37(7),pp.1222~1234. [34] Ehrlich, I. and G. S. Becker, 1972. “Market Insurance, Self-insurance, and Self-protection”,Journal of Political Economy, 80(4), pp.623~648. [35] Korenman, S. D. and D. K. Remler, 2016. “Including Health Insurance in Poverty Measurement: The Impact of Massachusetts Health Reform on Poverty”,Journal of Health Economics, 50, pp.27~35. [36] Korenman, S., D. K. Remler and R. T. Hyson, 2021. “Health Insurance and Poverty of the Older Population in the United States: The Importance of a Health Inclusive Poverty Measure”,The Journal of the Economics of Ageing, 18: 100297. [37] Lleras-Muney, A., H. Schwandt and L. R. Wherry, 2025. “Poverty and Health”,Annual Review of Economics, 17(1), pp.31~56. [38] Ligon, E. and L. Schechter, 2003. “Measuring Vulnerability”,The Economic Journal, 113(486), pp.C95~C102. [39] Martin, D. P., P. Diehr, K. F. Price and W. C. Richardson, 1989. “Effect of a Gatekeeper Plan on Health Services Use and Charges: A Randomized Trial.”,American Journal of Public Health, 79(12), pp.1628~1632. [40] Miller, S., N. Johnson and L. R. Wherry, 2021. “Medicaid and Mortality: New Evidence from Linked Survey and Administrative Data”,The Quarterly Journal of Economics, 136(3), pp.1783~1829. [41] Pinilla-Roncancio, M., J. L. Amaya-Lara, G. Cedeño-Ocampo, P. Rodríguez-Lesmes and C. Sepúlveda, 2023. “Catastrophic Health-care Payments and Multidimensional Poverty: Are They Related?”, Health Economics, 32(8), pp.1689~1709. [42] Sripa, P., B. Hayhoe, P. Garg, A. Majeed and G. Greenfield, 2019. “Impact of GP Gatekeeping on Quality of Care, and Health Outcomes, Use, and Expenditure: A Systematic Review”,British Journal of General Practice, 69(682), pp.e294~e303. [43] Wagstaff, A., 2002. “Poverty and Health Sector Inequalities”,Bulletin of the World Health Organization, 80, pp.97~105.
