Have lower-income groups benefited more from increased government health insurance subsidies? Benefit incidence analysis in Ningxia, China

China's government subsidies on the demand side-such as subsidizing medical insurance premiums-have accelerated progress towards universal health coverage. We examined whether the increased government subsidies had benefited the population, especially the poor. We conducted two rounds of household surveys and collected the annual claims reports of a rural medical insurance scheme in Ningxia (a relatively underdeveloped region in Western China). We used benefit incidence analysis to evaluate the distribution of benefits for different health services received by individuals with different living standards, as measured by the household wealth index. From 2009 to 2015, the benefit received per capita tripled from 101 to 332 CNY, most (>94%) of which was received for inpatient care. The overall distribution of benefits improved and became pro-poor in 2015 [the concentration index (CI) changed from -0.017 to -0.092], mainly driven by inpatient care. The poorer groups benefited disproportionately more from inpatient care from 2009 to 2015 (the CI changed from -0.013 to -0.093). County and higher-level inpatient care had the greatest improvements towards a pro-poor distribution. The distribution of subsidies for outpatient services significantly favoured the poorer groups in 2009, but less so in 2015 (CI changed from -0.093 to -0.068), and it became less pro-poor in village clinics (CI changed from -0.209 to -0.020). The increased government subsidies for the rural medical insurance scheme mainly contributed to inpatient care and allowed the poor to use more services at county and higher-level hospitals. China's government subsidies on the demand side have contributed to equity in benefit incidence, yet there is a noticeable increasing trend in utilizing services at higher levels of providers. Our findings also indicate that outpatient services need more coverage from rural medical insurance schemes to improve equity.