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Original research
Disparities in awareness and utilisation of National Essential Public Health Services between the floating population and the registered residents: a cross-sectional study in China
  1. Jin Wang1,2,
  2. Lan Bai3,
  3. Xinpeng Xu4
  1. 1Center for Health Policy and Management Studies, Nanjing University, Nanjing, Jiangsu, China
  2. 2Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China
  3. 3Department of Public Management, School of Health Economics and Management, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
  4. 4School of Public Health, Nanjing Medical University, Nanjing, China
  1. Correspondence to Dr Lan Bai; dreamhour{at}163.com; Dr Xinpeng Xu; xuxinpeng{at}njmu.edu.cn

Abstract

Objective There are differences between the floating population and the registered population in the awareness and use of the National Essential Public Health Services (NEPHS) due to the influence of China’s household registration system. The Equalization of Basic Public Health and Family Planning Services (EBPHFPS) policy aims to reduce disparities among populations by enhancing the migrant population’s access to basic public health services. The aim of this study is to examine the relationship between the EBPHFPS targeted at the floating population and the disparities in access to and utilisation of NEPHS between registered residents and the floating population.

Design A cross-sectional study.

Setting 8 cities (regions, autonomous prefectures) in China.

Participants 13 998 floating population and 14 000 registered residents in eight cities (regions, autonomous prefectures) were included in the analysis.

Outcome measures Three binomial variables, including awareness of NEPHS, acceptance of health education and establishment of health records, were used as outcome indicators to examine the relationship between the EBPHFPS and the disparities between the floating and registered populations.

Methods A linear regression model, fairness gap calculation and propensity score matching were used to explore the associations.

Results The areas that implemented EBPHFPS exhibited an 8.3% increase in awareness of the NEPHS (p<0.01) and a 4.0% increase (p<0.05) in the likelihood of individuals having received health education within the previous year compared with the areas without the policy implementation. In contrast to registered residents, however, the floating population still faces significant disparities in NEPHS awareness and utilisation. Compared with areas without the equalisation policy, the inequality of opportunity in health education of the floating population in implementation areas is significantly lower (p<0.01), whereas no significant difference is observed in the inequality of opportunity regarding NEPHS awareness among the floating population (p>0.1). The floating population in the pilot areas of the policy encountered greater disparities in the establishment of health records (p<0.01).

Conclusions Positive associations between the EBPHFPS policy and NEPHS awareness and utilisation among the floating population were demonstrated to some extent; however, the floating population was still confronted with a degree of inequality of opportunity. The government needs to develop target-oriented policies and a guaranteed mechanism to ensure access to NEPHS among the floating population.

  • China
  • Health Equity
  • Health Services Accessibility
  • Health policy

Data availability statement

Data are available in a public, open access repository. The data employed in our study are available on the website of China Migrants Dynamic Survey (CMDS) (https://chinaldrk.org.cn/wjw/%23/home). The data belong to the China National Health Commission and are free for researchers. We submitted the application on the website and received the data package. Researchers can log on to the China Migrant Population Data Platform (https://www.chinaldrk.org.cn/wjw/%23/home), and follow the prompts on the website to register an account for free. Anyone who wants to obtain the CMDS data needs to submit a research plan and an application form to the platform. The application form needs to be authorised by the researchers’ institution. Researchers also need to sign a data use agreement and guarantee that they will use the data in accordance with the requirements of the agreement and would not transfer the data to any third party.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • The fairness gap method was used to calculate the inequality of opportunity regarding the disparities in awareness and utilisation of National Essential Public Health Services (NEPHS) between the floating population and the registered residents.

  • The China Migrants Dynamic Survey (CMDS) dataset was employed in this study to investigate the associations between the disparities in population between the two groups and an equalisation policy targeted at the floating population.

  • The causal impact of the equalisation policy cannot be determined since the data employed are cross-sectional.

  • Recall bias is inevitable and may result in an underestimation of NEPHS utilisation since the CMDS is self-reported.

Introduction

The acceleration of urbanisation has substantially increased the likelihood of population migration. From 1982 to 2021, the number of floating populations, defined as those whose current residence is inconsistent with their household registration, is on the rise overall in China. The floating population was approximately 6.57 million in 1982. At the end of 2021, the total population amounted to 1412.6 million, with the floating population reaching 384.67 million, or 27.23% of the total population.1 However, the rights and interests of the floating population cannot be effectively guaranteed due to the dearth of stable housing for the floating population and the household registration system in China. Xiang Biao noted that a significant proportion of the floating population, characterised by low income and inadequate health literacy, is vulnerable to a range of diseases as a result of their deplorable living conditions.2 Moreover, the floating population is characterised by high mobility, poor living conditions and an inadequate social security system.3 Consequently, the floating population generally faces higher health risks compared with locally registered residents.

China has been implementing the National Essential Public Health Services (NEPHS) since 2009. The NEPHS aims to provide all residents with standardised preventive healthcare services. The financial burden associated with these services is borne jointly by the central and local administrations, and does not fall on individuals. The NEPHS has witnessed an expansion of its service categories from 9 in 2009 to 14 in 2017, and the per capita financial subsidy standard has risen from ¥15 in 2009 to ¥89 in 2023.4–6 Several studies have investigated the beneficial impacts of NEPHS utilisation on various aspects of the floating population, such as the treatment and control of chronic diseases,7 8 health status,9–12 accessibility and utilisation of healthcare services,13–15 multidimensional poverty16 and settlement intentions.17 While the NEPHS attempts to ensure that all floating population and registered residents have equal access to NEPHS awareness and utilisation, most floating population is excluded from NEPHS in the initial stage of policy implementation, and they are unable to access basic public health services as registered residents.18 Consequently, the NEPHS utilisation by the floating population is relatively low compared with that of local residents.19–23 This is intricately connected to the characteristics of China’s health system and the floating population. The distribution of China’s health resources resembles an inverted pyramid structure. The majority of health resources are concentrated in secondary and tertiary health facilities. NEPHS supply is impacted by the limited resources of primary health facilities.24 From a demand perspective, some studies have revealed that the floating population exhibits a higher level of ignorance or lack of understanding of NEPHS and participation processes compared with the registered local population. This poses challenges for primary health facilities in terms of effective health management for this group.25 26

In 2013, the Pilot Work Plan for the Equalisation of Basic Public Services for Health and Family Planning of the Floating Population was released, which introduced the Equalization of Basic Public Health and Family Planning Services (EBPHFPS) as a pilot policy for the floating population in 40 cities across 27 provinces. The EBPHFPS policy aims to enhance the accessibility of basic public health services for the floating population, thereby increasing NEPHS utilisation and promoting equal opportunities for NEPHS. Current research on the impact evaluation of the policy is quite limited. Some studies indicated that EBPHFPS can significantly improve the health status of the floating population27 and significantly lower the prevalence of diseases within this group.28 Another study discovered that EBPHFPS adversely affected the long-term settlement intentions of the floating population.29 Currently, no studies have examined the relationship between the EBPHFPS policy and the utilisation of NEPHS by the floating population, nor the relationship between EBPHFPS and the disparities in NEPHS awareness and utilisation between the floating population and the registered population. The aim of this study is to examine the relationship between the EBPHFPS targeted at the floating population and the disparities in access to and utilisation of NEPHS between registered residents and the floating population. Specifically, this paper aims to address the following three questions: (1) Does the establishment of health records, awareness of NEPHS and acceptance of health education exhibit a significant correlation with the implementation of EBPHFPS policy among the floating population?; (2) Compared with registered residents, does the floating population encounter any disparities in the awareness and utilisation of NEPHS? and (3) Does the existence of disparities correlate significantly with the implementation of the EBPHFPS policy? The findings would serve as a foundation and provide reference for optimising the EBPHFPS policy, enhancing the health status of the floating population, and narrowing the health disparity between the floating and the registered populations.

Theoretical analysis and research hypotheses

Roemer introduced his theoretical framework on the concept of equal opportunity, drawing inspiration from various equality concepts proposed by his predecessors.30 31 The central premise of the theory is that inequality in individual welfare resulting from uncontrollable circumstance factors is considered unfair and necessitates intervention, whereas inequality arising from effort factors attributable to individual responsibility is deemed acceptable and does not require intervention by public sector affairs. The registered population is more likely to use NEPHS because they are in a more favourable environment, namely their registered location. Their status as a registered resident confers upon them an advantage over the floating population with regard to awareness of and access to public health resources. The registered residence system, the financing and fund distribution mechanisms, as well as the obstacles to cultural and social integration, collectively hinder the floating population’s effective access to NEPHS. Consequently, disparities in the utilisation of NEPHS can be observed between the two groups of population. The EBPHFPS policy targeted for the floating population has the potential to significantly enhance this group’s health literacy, raise their awareness of NEPHS and promote NEPHS utilisation. By implementing the EBPHFPS policy, the two groups would have equal opportunities to receive homogeneous NEPHS, effectively narrowing the disparities between the floating and registered populations. Consequently, this study proposes the following hypotheses:

Hypothesis 1: the implementation of EBPHFPS policies in some locations is associated with improved awareness and utilisation of NEPHS among the floating population.

Hypothesis 2: there exist disparities in opportunities between the floating and registered populations in terms of awareness of NEPHS, the establishment of health records and acceptance of health education.

Hypothesis 3: the disparities in awareness of NEPHS, establishment of health records and acceptance of health education between the floating and the registered populations in the area implementing the EBPHFPS policy are lower.

Methods

Data source

This study employed the C and D parts of the 2017 China Migrants Dynamic Survey (CMDS) dataset.32 The survey was conducted by the National Health Commission. To compare the differences in public health service utilisation and health between registered residents and the floating population, the survey was conducted in eight representative cities (regions, autonomous prefectures) that represent the eastern, central and western regions of China. These cities include Qingdao, Zhengzhou, Su Zhou, Changsha, Guangzhou, Jiulongpo, Xishuangbanna and Urumqi. The survey used a stratified, multistage, proportional-to-scale (PPS) sampling method. In the first stage, townships (towns and streets) were selected based on the PPS method; in the second stage, village (residential) communities were selected according to the PPS method; finally, individual respondents were selected from these village (residential) communities during the third stage. The respondents fall into two categories. The first type of respondents is the floating population aged 15 years and above who have been residing in the inflow place for at least 1 month but are not registered in the district (county, city), excluding the population flow caused by travelling, visiting a doctor, going out on business, visiting relatives and other reasons. The survey of registered residents employs the quota approach, which ensures the same number of locally registered residents within the sample point according to the same gender and age as the floating population. The investigation is carried out by trained investigators using smart phones or iPads installed with computer-aided interview systems to conduct face-to-face interviews. The questionnaire encompassed information regarding family members, financial resources and spending, employment, migration characteristics (migrant population), as well as health and public services. The survey employed a sample size design to ensure that the relative error of three survey indicators—the proportion of unmarried working-age population, the proportion of employed working-age population and the proportion of local residents in the future—would be limited to 3% with a confidence level of 95%. In accordance with this objective, 13 998 floating populations and 14 000 registered residents in eight cities (states and districts) were ultimately surveyed.

Among the eight survey sites mentioned above, Qingdao, Zhengzhou and Changsha are among the 40 cities in the pilot of the EBPHFPS policy. The remaining five regions are the non-pilot areas of the EBPHFPS policy, allowing us to investigate the association between the EBPHFPS policy and the NEPHS awareness and utilisation among the floating population, as well as the association of the policy and the disparities between the floating and the registered populations.

Measurement

Dependent variables

Given the availability of indicators, the dependent variables in this study include the awareness of NEPHS, the establishment of health records in the inflow place and the acceptance of health education.

Based on the question ‘Have you heard of the NEPHS?’ in CMDS, we created a dummy variable indicating whether an individual heard of the NEPHS. Respondents who answered no were considered to be unaware of the NEPHS (value=0), while those who answered yes were aware of the NEPHS (value=1).

Based on the question ‘Has the local health record been established for you?’, a dummy variable was created to indicate whether the local health record is established. There are four responses to this question: (1) yes, it has been established; (2) not established, never heard of; (3) no, but I have heard of it; (4) I don’t know. The respondents who answered ‘yes, established’ were assigned a value of 1, indicating that this group of population has established health records locally. The respondents who selected the other options were assigned a value of 0, indicating that they did not establish health records in inflow areas.

Health education is based on the question ‘Have you received health education in the following aspects in your current residence in the past year?’ The answer to this question includes nine types of health education, including occupational disease prevention and control, sexually transmitted diseases and AIDS prevention and control, reproductive health and contraception, tuberculosis prevention and control, smoking control, mental health, chronic disease prevention and control, maternal and child healthcare/prenatal care, and self-rescue in public emergencies. We created a dummy variable with a value of 1 indicating that respondents had received at least one of the health education in the previous year, and a value of 0 indicating that respondents had not received any of the health education in the previous year.

Independent variables

The most important independent variable in this study was a dummy variable indicating whether or not respondents reside in areas where the EBPHFPS policy is piloted. Specifically, if a respondent resides in 1 of the 40 pilot cities, they will be regarded as the treatment group. If the respondents are from other cities, they will constitute the control group. In our study sample, residents of Qingdao, Zhengzhou and Changsha were in the treatment group, while residents of the other five areas were considered to be in the control group.

Covariates

Referring to the existing studies,19 we have controlled for other covariates associated with the awareness and utilisation of NEPHS, which primarily consist of four aspects: demographic characteristics, socioeconomic status, accessibility of health resources and individual health status. Age, gender (0=male, 1=female), family size, type of residence (0=rural, 1=urban), minority (0=no, 1=yes) and marital status (1=unmarried, 2=first marriage, 3=remarried, 4=divorced, 5=widowed, 6=cohabitation) were among the demographic characteristics. Included in socioeconomic status were monthly household income, education level (1=below primary school, 2=elementary school, 3=junior high school, 4=senior high school, 5=junior college, 6=undergraduate, 7=graduate), employment (0=no, 1=yes), occupation type (1=unemployed, 2=responsible person for state organs, party and mass organisations, enterprises and public institutions, 3=professional and technical staff, 4=civil servant, clerical personnel and related personnel, 5=businessperson, 6=vendor, 7=caterer, 8=housewife, 9=cleaner, 10=security guard, 11=decorator, 12=express delivery person, 13=other business and service personnel, 14=production personnel in agriculture, forestry, animal husbandry, fishery and water conservancy, 15=manufacturer, 16=transport personnel, 17=building industry personnel, 18=other production and transportation equipment operator and related personnel, 19=no fixed occupation, 20=others) and health insurance coverage (0=no, 1=yes). Employment was determined by whether respondents had worked for at least 1 hour in the week prior to the survey (0=no, 1=yes). For health insurance, individuals were asked if they got the following types of insurance: Urban Employee Basic Medical Insurance, Urban Resident Basic Medical Insurance, Coordinating Urban and Rural Basic Medical Insurance, New Cooperative Medical System and free medical insurance. The above five dummy variables of health insurance are added to the model, with a value of 1 indicating that the individual is covered by a specific type of insurance and 0 indicating that the individual is not covered by a specific type of insurance. The accessibility was determined by asking the distance between the respondent’s residence and the nearest health facility (1=within 15 min, 2=16–30 min, 3=31–60 min, 4=more than 60 min). Furthermore, three indicators were employed to measure the health status of individuals. In the CMDS data, each individual was surveyed ‘Have you been ill or injured in the past year?’ with three possible responses: 1=no; 2=yes, and it happened within the past 2 weeks; 3=yes, and it occurred 2 weeks ago. This variable was recoded with a value of 0 indicating no illness or injury in the past year and a value of 1 indicating illness or injury in the past year. Additionally, we included hypertension (0=no, 1=yes) and diabetes (0=no, 1=yes) as two proxy variables for health status.

Statistical analyses

Regression analysis

This study first used the regression analysis method to examine the associations between the EBPHFPS and NEPHS awareness and utilisation for the floating population. The specific model is defined as follows:

Embedded Image(1)

In model (1), yip refers to the awareness and utilisation of NEPHS of individuals in region p, including whether individuals heard of NEPHS, whether the health records have been established in the past year locally and whether at least one type of health education has been received in the past year. pilotip indicates whether the region p has implemented the EBPHFPS for the floating population. If the area is on the pilot list, the value is assigned 1; otherwise, it will be assigned a value of 0. Xip represents other covariates at the individual level, and Di represents the dummy variable of each region. In the above model, β is the coefficient that we focus on, which represents the association between the EBPHFPS and NEPHS awareness and utilisation for the floating population.

Measurement of the fairness gap

Under the theory of equal opportunity, inequality of opportunity is measured primarily by the counterfactual method. Assuming the inequality of opportunity faced by each person in the awareness of NEPHS is Embedded Image, where Embedded Image is counterfactual awareness of NEPHS when the status of the floating population changes into the registered local population under the implementation of the policy, and y is the actual awareness of NEPHS by the floating population under the implementation of the EBPHFPS policy.

To calculate the fairness gap, we first regressed the awareness of NEPHS to the dummy variable indicating whether the EBPHFPS policy is implemented in the sample of the registered population and obtain the corresponding coefficient of the variable Embedded Image . Then, we calculated the awareness value of NEPHS of individuals in the context among the floating population status Embedded Image . By subtracting the actual value of the NEPHS awareness of the floating population from the counterfactual estimate, the fairness gap of the NEPHS faced by the floating population (Embedded Image) was obtained. Similarly, we can calculate the inequality of opportunity encountered by the floating population in utilisation of NEPHS.

Propensity score matching

To further examine the association between the EBPHFPS policy and the inequality of opportunity, we employed the propensity score matching method. Through propensity score matching, we can control the differences in observable characteristics between the treatment and control groups, and hence reduce the possibility of estimation bias when calculating the associations.

Patient and public involvement

Patients and the public were not involved in the design, or conduct, or reporting, or dissemination plans of this study.

Results

Characteristics of study population

Table 1 lists the characteristics of the floating population and registered population in the pilot and non-pilot areas. The average ages of the registered population and floating population were both 35.8 years old in the areas without pilot policies, and 34.8 years old and 34.7 years old in the areas with pilot policies, respectively. The proportion of women in non-pilot areas and pilot areas was 49% and 48%, respectively. Most of the individuals were married. The majority of the floating population had completed junior high school or senior high school, while most of the registered population had completed senior high school or junior college. 78% and 91% of the floating population did at least 1 hour of work in the week before the survey in the pilot and non-pilot areas, respectively. Moreover, in terms of the accessibility of medical services, the proportion of the registered population within 15 min from the nearest health institution is greater than that of the floating population, and the proportion is greater in the areas where the equalisation policy was implemented. The 2-week morbidity, and prevalence of hypertension and diabetes were lower in the implementation areas.

Table 1

Characteristics of the study sample

Table 2 showed the statistical results of the three outcome variables. In areas where the equalisation policy is implemented, the awareness rates of the registered and floating population on NEPHS are 76.4% and 64.9%, respectively. 72.9% of the registered population and 61.1% of the floating population were aware of NEPHS in areas where the equalisation policy was not implemented. 63.33% of the registered population and 31.32% of the floating population established health records in the areas where the policy was implemented. 56.7% of the registered population and 31.65% of floating population established health records in the non-implementation areas. 25.17% of the floating population in implementation areas had not established health records but had heard of it. This proportion is 21.99% in the non-implementation areas.

Table 2

Descriptive statistical analysis of awareness and utilisation of NEPHS

The association of EBPHFPS policy and NEPHS awareness and utilisation among the floating population

The linear regression model was employed to assess the association of the EBPHFPS policy and NEPHS awareness and utilisation among the floating population. The results indicated that the floating population in the pilot areas was more likely to be aware of NEPHS and accept health education (table 3). Specifically, the NEPHS had an awareness rate that was 8.3% higher (p<0.01) and a 4.1% (p<0.05) greater chance of obtaining health education in the past year compared with areas where the policy was not implemented. While the EBPHFPS policy had a negative correlation with the establishment rate of health records for the floating population, with an average decrease of 3.1%, this effect did not reach statistical significance (p>0.05). We also conducted logit regression to verify the robustness of the results, and the estimated results are consistent with the linear results (online supplemental table A1).

Table 3

Regression analysis results

Fairness gap calculation

The fairness gap faced by the floating population in terms of NEPHS awareness and utilisation is shown in table 4. Without taking into account any adjustments for the covariates, the floating population faces a fairness gap of 11.45% in the NEPHS awareness rate in the implementation areas. The floating population experiences a disparity in health education, with a fairness gap of 6.31% in the implementation areas and 8.93% in the non-implementation areas. The disparities in the establishment of health records experienced by the floating population in the implementation and non-implementation areas are 35.51% and 28.36%, respectively.

Table 4

Measurement of the fairness gap in awareness and utilisation of NEPHS

After controlling for the covariates, the results revealed that the fairness gap in NEPHS awareness faced by the floating population in the implementation and non-implementation areas was 7.19% and 5.19%, respectively, and the fairness gap in the acceptance of health education faced in the implementation and non-implementation areas was 3.81% and 8.10%, respectively. Regarding the establishment of health records, the fairness gap encountered by the floating population in areas where the policy is implemented and not implemented was 35.52% and 22.55%, respectively.

The associations between EBPHFPS policy and the disparities in NEPHS awareness and utilisation between the two groups of population

We used the nearest neighbour matching method, hierarchical matching method and kernel matching method to match individuals from implementation and non-implementation areas. After matching, the average treatment effect on the treated is determined by calculating the difference between the regions where the EBPHFPS policy is implemented and the regions where it is not. Table 5 displays the estimated results of the associations under different outcome variables and matching strategies.

Table 5

The association between the equalisation policy and the fairness gap

In terms of NEPHS awareness, results under the hierarchical matching and kernel matching strategies showed that the fairness gap between the floating and the registered populations in the pilot areas was significantly lower. After controlling for the confounders, the estimated results indicated that the disparity in NEPHS awareness between the two groups of population in pilot areas was 0.3–0.6% lower than that in non-pilot areas. However, these differences were not statistically significant.

The fairness gap in accessing health education for the floating population in pilot areas is 4.9–5.6% lower than that in non-pilot areas, regardless of whether the covariate is controlled. The aforementioned effects exhibited statistical significance at the 1% level, irrespective of the matching approach applied. Furthermore, there is no negative association observed between the equalisation policy and the fairness gap in the establishment of health records, and it even widened the disparity in establishing health records for the floating and registered populations.

Discussion

Based on the natural experiment of the EBPHFPS policy for the floating population, this study investigated the association between the EBPHFPS policy and the awareness and utilisation of NEPHS for the floating population. Under the theory of equal opportunity, the inequality of opportunity that existed in the awareness and utilisation of NEPHS for the floating population and registered residents in the implementation and non-implementation of EBPHFPS policy was calculated, and the association between the EBPHFPS policy and inequality of opportunity between the two groups of populations is estimated through the propensity score matching method.

Our findings demonstrated the effectiveness of the EBPHFPS policy. In 2009, the Central Committee of the Communist Party of China and the State Council released Opinions on Deepening the Reform of the Medical and Health System, which suggested the initiation of NEPHS in China. NEPHS aims to deliver cost-free, equitable and accessible basic public health services for all residents, with the ultimate goal of improving the health status of the residents. NEPHS has expanded from 41 items in 9 categories in 2009 to 55 items in 14 categories in 2017.5 The Chinese government has taken a number of measures to guarantee equitable access to NEPHS for both local residents and the floating population.18 In 2014, China implemented the EBPHFPS policy for floating populations in 40 cities, which aimed to provide standardised NEPHS to the floating population and local residents to improve NEPHS utilisation by the floating population.33 During the execution of the EBPHFPS policy, the floating population exhibits a higher level of awareness of NEPHS and a greater probability of accepting health education.

Nevertheless, our investigation also uncovered that the implementation of the equalisation policy did not result in an increased rate at which health records were established. This is inconsistent with the results of a previous study, which found that EBPHFPS can improve the coverage of health records of the floating population by approximately 6.9%.28 The variations in the findings can be mostly attributed to differences in the data employed. The 2014 CMDS data in that study, which represent the initial stage of EBPHFPS implementation, suggest that EBPHFPS has an immediate impact. However, the beneficial impact of the EBPHFPS on the floating population about the establishment of health records has diminished with time. A health record is an essential instrument for the management of health information, encompassing personal basic information, health examinations, health service utilisation and other relevant records.34 It can facilitate individuals in obtaining timely health information, making informed health-related choices and implementing efficient personal health management. Furthermore, health records enable ongoing communication between healthcare professionals and patients, as well as the provision of tailored health management services.35 The low establishment rate of health records among the floating population can be explained by two aspects. Compared with the local residents, the floating population has lower awareness of healthcare, resulting in less frequent utilisation of NEPHS.36 The former National Health and Family Planning Commission and other ministries and commissions jointly issued the Notice on completing the National Basic Public Health Service Projects in 2017, which stated that the establishment rate of health records must exceed 75%.37 Shi et al discovered that only 30.2% of the young floating population had established health records, which was far below the required level.18 Furthermore, NEPHS is predominantly offered by primary healthcare centres, which have very low human health resources. The scope of work in NEPHS encompasses various topics. Consequently, the health personnel of the primary healthcare centres face relatively high work pressure, which will negatively impact the efficiency and quality of NEPHS delivery.5 38

Moreover, we discovered that the floating population experiences disparities in NEPHS awareness and utilisation relative to the registered population, regardless of the implementation of the EBPHFPS policy. However, the health education opportunities for the floating population in the implementation areas are significantly more equitable compared with the non-implementation areas. This suggests that the equalisation policy has improved the access of the floating population to health education and narrowed the disparity between the floating and registered residents. It was noted that the disparity in NEPHS awareness between the two groups in areas that implemented equalisation has not diminished, and the disparity in establishing health records was even wider. This could be attributed to disparities in the accessibility of health information. Local residents who are officially registered have a greater understanding of the local health service system and medical security system. However, the floating population is not officially registered and faces an unfamiliar health service system. Consequently, they have a less ability than local residents to obtain relevant information about NEPHS. Furthermore, one study revealed that young migrants, as a result of their temporary residence, employment or trade, do not have sufficient time to learn about local preventive healthcare information. In addition, their healthcare awareness is insufficient, and they lack the motivation to establish health records.18 The externalities of the EBPHFPS policy to enhance publicity may also increase the likelihood of registered residents establishing health records, thereby widening the gap between the two groups in terms of health records establishment. The healthy immigrant effect may be another reason for the lower utilisation of NEPHS by the floating population compared with local residents. Due to the self-selection of the floating population, their health status is higher than that of local residents and they tend to use fewer preventive healthcare services.27

Our findings have certain implications for improving relevant policies. First, the government can increase awareness and utilisation of NEPHS among the floating population through a variety of methods. Despite the fact that the equalisation policy has increased the awareness of the floating population, there is still a disparity in awareness between the floating population and registered residents. To help the floating population better enjoy NEPHS, it is imperative to develop target-oriented policies and a guaranteed mechanism, as well as enhance the dissemination of information and promotional efforts. For instance, in the working industry with a more intensive floating population, it is effective to use enterprise-based propaganda and educational methods to raise awareness about NEPHS and increase the rate of health record establishment.18 Second, it is essential to continue strengthening health education for the floating population. Existing studies have demonstrated that health education for the floating population can significantly improve their health status.19 Our study revealed that in the policy piloted areas, the opportunities for the floating population to receive health education have increased, and the disparity between them and the registered residents has narrowed. Health education on the prevention and control of specific occupational diseases should be implemented to enhance the health literacy of the floating population. Third, the government must increase investment in the primary healthcare centre, including human and financial resources. There are a variety of categories of NEPHS, and research indicated that job burnout is prevalent among primary healthcare providers in China.39 Only by increasing the corresponding investment can the quality of NEPHS be effectively guaranteed and the health concept of shifting from treatment-centred to health-centred be put into practice. Fourth, there is still a lack of attention to multisectoral cooperation in the field of primary healthcare.40 To address the current issue of unequal access to basic public health services among different groups, from the perspective of the health system, we should go beyond the vertical approach and attach importance to and strengthen the interaction between public health institutions and other departments or institutions.41 42 Based on the social determinants of health, we can jointly promote the health of the floating population, meet the changing health needs of the population and resolve the health inequity problem among different groups. Furthermore, our study also provides a new way to evaluate relevant health policies. Prior research found that there is still a lack of quality-oriented primary care service evaluation in China.40 When conducting health policy evaluation research in the future, we should not only pay attention to the direct effect of the policy itself but also to the fairness of the implementation of the policy to the utilisation of services for different groups, so as to comprehensively improve the health effect of the policy.

There are some limitations in this study. First, causality cannot be determined due to cross-sectional data. Longitudinal data can be used in the future to track this issue. Second, recall bias is inevitable and may result in an underestimation of NEPHS utilisation since the CMDS is self-reported. In addition, while the indicators we use, such as NEPHS awareness, the establishment of health records and the acceptance of health education, are closely associated with the direct impact of the implementation of the EBPHFPS policy, they do not completely capture the effect of the EBPHFPS policy. Third, it should be admitted that the use of secondary data introduces the possibility of bias in the selection of cities. The survey was not specifically designed and executed to collect samples based on the implementation of policies. This may pose challenges in generalising our research samples to a broader context. Therefore, it is crucial to interpret our study findings with caution.

Conclusions

Using the natural experiment of the EBPHFPS policy for the floating population, this study examined the association between the EBPHFPS policy and the awareness and utilisation of NEPHS among the floating population. Additionally, it investigated the associations of the EBPHFPS policy and the inequality of opportunity faced by the floating population based on the theory of equal opportunity. The results indicated the floating population has a higher rate of NEPHS awareness and a greater likelihood of receiving health education in the implementation areas of the EBPHFPS policy. Nevertheless, there are still disparities for the floating population in NEPHS awareness and utilisation. The health education opportunities for the floating population in the pilot locations exhibit a notable reduction in inequality. The government needs to increase awareness and establishment of NEPHS among the floating population and formulate target-oriented policies and a guaranteed mechanism to enable the floating population to receive NEPHS fairly.

Data availability statement

Data are available in a public, open access repository. The data employed in our study are available on the website of China Migrants Dynamic Survey (CMDS) (https://chinaldrk.org.cn/wjw/%23/home). The data belong to the China National Health Commission and are free for researchers. We submitted the application on the website and received the data package. Researchers can log on to the China Migrant Population Data Platform (https://www.chinaldrk.org.cn/wjw/%23/home), and follow the prompts on the website to register an account for free. Anyone who wants to obtain the CMDS data needs to submit a research plan and an application form to the platform. The application form needs to be authorised by the researchers’ institution. Researchers also need to sign a data use agreement and guarantee that they will use the data in accordance with the requirements of the agreement and would not transfer the data to any third party.

Ethics statements

Patient consent for publication

Ethics approval

This was a secondary analysis of publicly available data, and no participant consent forms were required to access this dataset. All procedures performed in this study were in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Ethical approval for this study and for analysing the secondary data was obtained from the Ethics Committee of Nanjing Medical University (REC: NJMU2022040).

Acknowledgments

We thank the Migrant Population Service Center, National Health Commission People's Republic of China, for providing the CMDS 2017 data.

References

Footnotes

  • JW and LB contributed equally.

  • Contributors LB is the guarantor of the study. LB and XX designed the study. JW led the data analysis and wrote the original draft. XX acquired the funding and participated in the data analysis. LB and XX made important contributions to the revision of the manuscript. JW, LB and XX participated in the revision of the manuscript and the improvement of English writing. All authors have read and approved the final manuscript.

  • Funding This study was supported by the Science and Technology Climbing Engineering Scientific Research Innovation Project-Innovative Research Cultivation Project, Nanjing Medical University (grant number 06).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.