# Policy stringency during the COVID-19 pandemic and healthcare services utilization in China: An interrupted time-series analysis

## TL;DR

This study shows how China's strict Zero-COVID policies disrupted healthcare use for years, with slow recovery and regional differences in access.

## Contribution

The study provides the first nationwide, long-term analysis of healthcare utilization in China during and after the Zero-COVID policy.

## Key findings

- Healthcare utilization in China dropped significantly during the pandemic, with 7% fewer outpatient visits and 13% fewer inpatient discharges than expected.
- Strict pandemic policies were strongly linked to reduced healthcare use, with a 10-point policy increase associated with a 7.2% drop in outpatient visits.
- As of April 2024, most regions still had not fully recovered, with 65% showing below-expected outpatient visits and 74% for inpatient discharges.

## Abstract

The COVID-19 pandemic has profoundly impacted healthcare systems worldwide, with China presenting a unique case. As the first country to report COVID-19 cases and the last to lift its stringent Zero-COVID policy, China presents a distinctive context for understanding the long-term effects of the pandemic on healthcare utilization. This study provides a comprehensive analysis of healthcare utilization trends in China over more than four years of the pandemic, focusing on how different phases, including the Zero-COVID policy and its cessation.

We conducted an interrupted time-series analysis of monthly healthcare utilization data from January 2015 to April 2024, including outpatient visits and inpatient discharges, across Mainland China, controlling for underlying secular trends and patterns. Hospital-based healthcare utilization data were sourced from the National Health Commission of China, and daily Policy Stringency Indices (higher values indicating stricter control policies) were obtained from Oxford’s COVID-19 Government Response Tracker. We modeled changes in healthcare utilization using negative binomial regression, comparing actual outcomes with counterfactual estimates based on pre-COVID trends. We assessed healthcare utilization during key pandemic phases, including the post-Zero-COVID period. Healthcare utilization in China experienced substantial declines during the pandemic, with an estimated reduction of 1.21 billion (7%) outpatient visits and 140.9 million (13%) inpatient discharges compared to expected levels from January 2020 to April 2024. The most pronounced declines occurred during the initial pandemic waves and coincided with periods of stringent Zero-COVID measures. Negative associations between the Policy Stringency Index and healthcare utilizations were observed. Before the lifting of the Zero-COVID policy, a 10-point increase in the Policy Stringency Index was associated with a 7.2 percentage point decrease in outpatient visits and a 6.2 percentage point decrease in hospitalizations. Although healthcare utilization gradually rebounded following the cessation of the Zero-COVID policy, as of April 2024, utilization remained below expected levels in 20 (65%) of the 31 regions for outpatient visits and in 23 (74%) for inpatient discharges. Regional disparities were evident, with more developed areas, such as Shanghai and Beijing, experiencing the largest absolute reductions after adjusting for population size. In Shanghai, outpatient visits declined by 4,997 and hospitalizations by 241 per 1,000 people. In contrast, the largest relative reductions occurred in less developed regions, where outpatient visits dropped by 16% in Guizhou and hospitalizations declined by 27% in Shanxi. Use of aggregated routine health system data limited individual-level analyses, assessment of care quality, and disentangling of causal pathways.

The COVID-19 pandemic and Zero-COVID policies were associated with substantial and enduring disruptions to healthcare utilization in China, characterized by slow recovery and regional disparities in access. These findings underscore the importance of strengthening healthcare systems to enhance resilience and better balance public health interventions with the maintenance of essential healthcare services in anticipation of future public health crises. Continued targeted efforts are needed to address the delayed recovery, particularly in regions with already strained healthcare infrastructure, and to ensure equitable healthcare access across the country.

The COVID-19 pandemic was associated with major disruption to healthcare systems globally, with substantial variation in the extent of disruption and recovery across countries

Existing studies on China have been limited to specific regions or timeframes, primarily assessing short-term association such as early outbreaks in 2020 or localized surges like the 2022 Shanghai Omicron wave.

China’s unique pandemic trajectory, characterized by prolonged Zero-COVID policies followed by an abrupt cessation, remains insufficiently studied in terms of its long-term consequences for healthcare access.

This study performed a comprehensive, nationwide evaluation of healthcare utilization trends in China over more than four years of the COVID-19 pandemic.

Integrating hospital-based healthcare utilization data with policy stringency indices, it quantifies the cumulative disruption and recovery of healthcare services across 31 regions.

Through interrupted time-series analysis, the study demonstrates that as of April 2024, healthcare utilization in most regions remains below pre-pandemic projections, with pronounced disparities between more and less developed areas.

The findings highlight persistent changes in healthcare utilization observed during periods of stringent pandemic control measures, underscoring the need for policies that balance infectious disease containment with the maintenance of essential health services.

The slow and uneven recovery in healthcare utilization may have long-term implications for population health, particularly in regions with already limited healthcare resources.

Future public health preparedness strategies should incorporate mechanisms to sustain essential medical services during crises, ensure equitable recovery across regions, and mitigate disruptions to healthcare access during future pandemics.

The use of aggregated routine health system data limited individual-level analyses and assessment of care quality

In a time-series analysis, Hong Xiao and colleagues investigate how different phases and shifts in policy stringency related to healthcare utilization in the first four years of the COVID-19 pandemic in China.