"Strengthening primary health care" is one of the focuses of China's health care reform, and the study of the efficiency and equity of rural medical and health resources allocation in China is of great significance in promoting the orderly development of primary health care services, but at present, there are few relevant literature based on the DEA-GIS methodology with both equity and efficiency.

To analyze the efficiency and equity of rural medical and health resources allocation in 29 provinces in China in 2020, in order to provide a reference for optimizing the allocation of rural medical and health resources and improving the rural medical and health service system in China.

The data for this study were collected from the Statistical Tables of Administrative Divisions of the People's Republic of China, the 2021 China Health Statistical Yearbook. After synthesizing the existing literature research, data availability and soliciting expert advice, the township hospitals and village clinics in 29 provinces in China (excluding Beijing, Shanghai, Hong Kong, Macao and Taiwan) were selected as the study objects, and the number of township hospitals and village clinics (hereinafter referred to as the number of health institutions) , the number of beds in township hospitals (hereinafter referred to as the number of beds) , and the number of health technicians in township hospitals and village clinics (hereinafter referred to as the number of health technicians) were used as input indicators; the number of consultations in township hospitals and village clinics (hereinafter referred to as the number of consultations) , and the number of hospital admissions to township hospitals (hereinafter referred to as the number of admissions) were used as output indicators. The data envelopment analysis (DEA) model was used to assess the efficiency of rural medical and health resources allocation in China, and the health resource agglomeration degree and geographic information system (GIS) technology were used to spatially map the rural medical and health resources allocation to analyze its equity.

In 2020, China's rural medical and health resources had 4 provinces with effective DEA, 7 provinces with weakly effective DEA, and 18 provinces with ineffective DEA. Among them, the DEA ineffective regions all had different degrees of excess inputs, and only Shandong Province and Tibet Autonomous Region had insufficient outputs. The results of regional analysis showed that rural medical and health resources were concentrated in the eastern region, followed by the central region, with the lowest degree of concentration in the western region.

The government needs to pay attention to improving the technical efficiency of rural medical and health resources allocation, and promote equity and efficiency by applying precise measures to each region based on optimizing the input and output structure, reducing resource redundancy, rationally coordinating the allocation of resources in the eastern, central and western regions.

The "Healthy China 2030" strategy has put forward higher demands for the allocation of health human resources, and more regional studies on the evaluation of the equity of health human resources have been conducted in China, but there is no overview of multiple categories of health human resources in various medical institutions from a national perspective.

To describe the trend and equity of 12 categories of health care institutions and 5 categories of health human resources in 31 provinces (autonomous regions and municipalities directly under the central government) nationwide from 2005-2021, so as to provide reference for the optimization of human resource allocation in various health institutions in the future.

National data on health human resources was collected from China Public Health Statistical Yearbook (2006-2012), China Health and Family Planning Statistical Yearbook (2013-2017) and China's Hygiene and Health Statistical Yearbook (2018-2022), demographic and economic data was collected from China Statistical Yearbook (2006-2022). The average annual growth rate and concentration index were calculated by collecting the per capita occupancy of each health human resource in medical and health institutions in each province (autonomous regions and municipalities directly under the central government) of China from 2005 to 2021, and the equity analysis was conducted based on the level of economic development.

The total number of health personnel in China continued to rise, with an average annual growth rate of 5.58%, with faster growth in rural areas at an average annual growth rate of 10.87%; the number of health personnel in community health service centers (stations) had the fastest growth rate (average annual growth rate of 18.05%), the number of personnel in health supervision offices grew at a lower rate (average annual growth rate of 0.18%), and the number of personnel in disease prevention and control centers showed a decreasing trend (average annual growth rate of -0.39%). Except for community health service centers (stations), the concentration index of the total number of health personnel in all types of medical institutions was <0.20.

The per capita occupancy of each health human resource in medical and health institutions is growing faster in rural areas, the equity of human resources across health institutions in China is good, but the total amount is insufficient, and important institutions and personnel categories need attention. Investment in human resources for rural health should continue to be strengthened, and the state and provinces should stabilize the public health workforce, improve the development of primary health service institutions, and expand equity and accessibility.

"Everyone enjoys essential medical and health services" and "achieving health equity" are core goals of the new healthcare reform initiated in 2009 in China. Rural middle-aged and elderly people are key target groups of healthy aging promotion, but there are few longitudinal studies on the equality in their use of health services during 10 years since the beginning of the new healthcare reform.

To understand the changes in health service utilization among middle-aged and elderly people in rural areas of Ningxia during 2009 to 2019, and to explore the factors affecting the equity of health service utilization.

The information related to health service utilization in middle-aged and elderly people aged 45 years and above in rural mountainous areas of southern Ningxia was obtained from the baseline survey conducted in 2009 and subsequent follow-up surveys in 2015 and 2019. The changes of health service utilization of this population before and after the new healthcare reform were analyzed by the χ² test. The concentration index (CI) and decomposition of CI technique were used to measure the equity in health service utilization and explore its associated factors.

The two-week consultation rates in these middle-aged and elderly people in 2009, 2015 and 2019 were 13.14% (973/7 406), 10.14% (943/9 302), and 12.75% (1 066/8 360), respectively, showing statistically significant difference (χ²=46.340, P<0.001). The hospitalization rates in them in 2009, 2015, and 2019 were 13.27% (983/7 406), 18.07% (1 681/9 302), and 22.93% (1 917/8 360), respectively, with statistically significant difference (χ²=245.657, P<0.001). The first leading cause of non-seeking healthcare for an illness within two weeks was financial difficulties〔58.35% (353/605) 〕in 2009, and was self-perceived mildness of symptoms in 2015〔34.47% (121/351) 〕 and 2019〔34.21% (117/342) 〕. In the three surveys, financial difficulties were the top reason for those needing hospitalization but not being hospitalized, accounting for 83.82 % (228/272) in 2009, 60.98% (75/123) in 2015, and 41.22% (54/131), respectively. The values of CI of the two-week consultation rate in the three surveys were 0.056 5, 0.012 8, and 0.018 6, respectively, and those of the hospitalization rate were 0.045 8, -0.011 0, and 0.002 0, respectively. Economic level, chronic disease, age, and family size were main contributing factors to the inequity in health service utilization.

A significant increase was seen in the use rate of inpatient service utilization in this population during the 10 years after the healthcare reform, but their utilization rate of outpatient health services needed to be improved. Health service utilization tended to return to equity, but it was still higher in high-income individuals. Economic level was the primary factor affecting the equity of health service utilization.

As global aging advances, the number of people with disability is increasing. Disability seriously affects quality of life and increases the burden caused by healthcare expenditure. Most domestic studies focus on disabilities in middle-aged and elderly people, but there is a lack of longitudinal studies on the fairness of health service utilization and changes in its associated factors in rural middle-aged and elderly people with disability.

To analyze the fairness of health service utilization and major associated factors in middle-aged and elderly people with disability in rural mountainous areas of southern Ningxia.

This study used data from three waves of the Rural Household Health Survey (including the baseline survey in 2009 and two follow-up surveys in 2015 and 2019), and selected middle-aged and elderly adults (≥55 years old) with disabilities from the surveyees as the participants. The health service utilization equity of sample population before the new healthcare reform launched in 2009 and during 10 years after the reform was analyzed by using concentration index, and factors affecting the equity were analyzed by decomposing the concentration index.

We selected 1 351 cases from the surveyees of 2009, 1 521 cases from the surveyees of 2015, and 685 cases from the surveyees of 2019. The concentration index for two-week visit rate in the participants was 0.119 9 for 2009, 0.052 1 for 2015, and 0.060 9for 2019. Women (CI=0.108 2, -0.084 1) had higher level of inequalities in heath service utilization than men (CI=-0.022 9, 0.029 5) in 2015, 2019 year. Upper-middle income and high income were major factors contributing to inequalities in health service utilization in this population in 2009, explaining 3.626 9% and 2.596 5% of the inequalities, respectively. In 2015, in addition to economic factors, marital status (married), degree of education (primary) and household size (moderate) were another major factor contributing to inequalities in health service utilization, explaining 0.478 6%、0.398 4%、-0.339 2% of the inequalities, respectively. And in 2019, besides economic factors, household size (advanced) and Age (70-74 years old) were major factor contributing to inequalities in health service utilization, explaining -0.953 4%、0.694 3% of the inequalities, respectively.

Rich-related inequalities were found in the use of care for an ill within two weeks in this group of people, in Ningxia the past decade of the new medical reform. The main influencing factors of equity gradually evolved from the relatively single phenomenon of economic income being the dominant factor to the situation where age, household size, economic income, and other factors interact in multiple ways. Moreover, the strength of association age, vocational type inequalities in health service utilization in women was greater than that in men.

The aim and mission of the new healthcare reform in China, namely, the healthcare reform initiated in 2009, are effectively implementing health policies to improve people's livelihood and well-being. As a domestic hot research topic, studies on the effectiveness of the new healthcare reform mainly focus on current cross-sectional data, but rarely involve longitudinal or panel data.

To explore the changes in health service utilization in married women of childbearing age in rural mountainous areas of southern Ningxia before and after 10 years of the new healthcare reform, and to identity the major causal factors of inequalities in the utilization.

This study used the results of the Rural Household Health Survey conducted in 2009 (baseline data) and in 2019 (10-year follow-up data). The direct standardization method was used to comparatively analyze the status of health service utilization in married female surveyees of childbearing age living in rural mountainous areas of southern Ningxia before and after the implementation of the new healthcare reform. The inequality in health service utilization and the contribution level of its associated contributory factors were measured by calculating and decomposing the concentration index (CI) .

The number of eligible participants was 4 935 in 2009, and 3 509 in 2019. Compared with 2009, the two-week hospital visit rate showed a slight increase (1.29%) in 2019, but the rate of consultation for chronic diseases decreased significantly (18.77%). In addition, the rates of hospitalization for those requiring hospitalization, gynecological examination, antenatal examination, hospital delivery and postnatal visits increased significantly, by a factor of 10.44%, 8.53%, 24.05%, 36.52% and 23.62%, respectively. The CI values for all indicators in both surveys were greater than 0, except for those for postpartum visit rate in the 2009 survey (-0.034 5) and two-week hospital visit rate in the 2019 survey (-0.016 9). Economic income, literacy, family size and age were major contributory factors of the inequality in health service utilization.

After 10 years of the new healthcare reform, the utilization of health services in married women of childbearing age in the areas of Ningxia improved, and tended to be more equitable, but a slightly higher utilization rate was found in high-income individuals.

The health care and health system reform is a worldwide issue. In 2009, China launched a new round of health care and health system reform. Over the past ten years, especially since the 18th National Congress of the Communist Party of China, the reform has brought tangible benefits to nearly 1.4 billion people. The decade of the new medical reform, which concentrates the interests of all parties, is a highlight of China's medical and health services. The discussion and demonstration of the reform effectiveness has become a hot topic in the academic field.

To sort out and analyze the data changes of the health status and equity of health service utilization of rural residents in Ningxia during the process of new medical reform and the reflected development effectiveness.

The baseline data was collected from the "Family Health Interview Survey for Rural Residents" in Ningxia in 2009, and the follow-up data in 2015 and 2019. The self-rated unhealthy rate and prevalence of chronic diseases were selected as indicators to measure the health status of residents, and the two-week consultation rate and hospitalization rate were selected as indicators to measure the health service utilization of residents. The concentration index (CI) and its decomposition method were used explore the health status and equity of health service utilization of rural residents in Ningxia in the past decade of the new medical reform.

During the decade of the new medical reform, the self-rated unhealthy rate of rural residents in Ningxia decreased, and the prevalence of chronic diseases increased year by year. The self-rated unhealthy rate in 2009, 2015 and 2019 was 20.37% (4 107/20 160), 17.75% (3 216/18 114) and 19.51% (3 527/18 074) ; the prevalence of chronic diseases was 13.01% (2 623/20 160), 19.45% (3 523/18 114) and 26.28% (4 750/18 074), respectively. The overall changes in health service utilization showed an upward trend, the two-week consultation rate in 2009, 2015 and 2019 was 6.43% (1 296/20 160), 5.66% (1 026/18 114) and 8.06% (1 457/18 074) ; the hospitalization rate was 8.89% (1 792/20 160), 10.66% (1 931/18 114) and 13.23% (2 392/18 074), respectively. Equity of health and health service utilization have been improved, the CI of the self-rated unhealthy rate of rural residents in Ningxia in 2009, 2015 and 2019 was -0.024 1, -0.095 2 and -0.098 0; the CI of the prevalence of chronic diseases in 2009, 2015 and 2019 was -0.001 3, -0.081 5 and -0.081 0, respectively; the CI of two-week consultation rate was 0.068 8, -0.011 3, -0.051 2, and the CI of two-week hospitalization rate was 0.039 0, -0.029 4, -0.061 2, respectively. The main influencing factors of equity gradually evolved from the relatively single phenomenon of economic income being the dominant factor to the situation where age, economic income, chronic diseases, education level and other factors interact in multiple ways.

The health status and equity of health service utilization of rural residents in Ningxia has been improved in the past decade of the new medical reform. However, more attention should be paid to new issues and inequities caused by the aging population and changes in social structure.

In recent years, China has attached great importance to strengthening the development of general practitioner (GP) workforce and primary care service system. To innovate the incentive mechanism for GP training and employment and improve the training system for GPs, the government has also promulgated a series of policies and put forward major reform measures involving many aspects.

To analyze and evaluate the fairness of distribution of general practitioner (GP) resources in China, and to provide theoretical support for scientific and equitable allocation of GP resources.

Data were sourced from five volumes of China Health and Family Planning Statistical Yearbook (2017—2021), China Health Statistical Yearbook (2017—2021), and China Statistical Yearbook (2017—2021) in June 2022, including the number of GPs, the number of people registered as general medicine professionals, the number of people who obtained the General Practitioner Certificate after training, the number of GPs per 10 000 population, and the number of practicing (assistant) physicians in China, in each geographical division (eastern, central or western), and in each regionin, and the annual gross domestic product (GDP), gross regional product (GRP), and the year-end total population data of each region during 2016 and 2020. Additionally, the total land area of each region was extracted from the China ABC column on the website www.gov.cn. The Lorenz curve and the Gini coefficient were used to analyze the fairness in the distribution of GP resources. The Theil index was used to analyze differences in the distribution of GP resources in eastern, central and western China.

The number of GPs in China increased from 209 083 in 2016 to 408 820 in 2020, showing a growth rate 95.53%. In 2020, the proportion of GPs among all practicing (assistant) physicians reached 10.01% (408 820/4 085 689), and the number of GPs per 10 000 population was 2.90. The Gini coefficients measuring demographic, economic, and geographical distribution inequalities of GP resources were 0.235, 0.178, 0.722, respectively for 2016, 0.231, 0.170 and 0.726, respectively for 2017, 0.225, 0.161 and 0.729, respectively for 2018, 0.177, 0.147 and 0.714, respectively for 2019, and 0.157, 0.136, and 0.707, respectively, for 2020. Overall, the Lorenz curve measuring the inequality in the distribution of GP resources by demographics or economy had lower degree of curvature than that by geography. A reduction was found in Theil index measuring unequal demographic, economic or geographical distribution of GP resources in 2020 compared with that in 2016 (from 0.046 to 0.020; from 0.022 to 0.013; from 0.482 to 0.428) .

During the five years, the distribution of GP resources in China presented the following features: the number of GPs increased rapidly and became an important part of the workforce of practicing (assistant) physicians, the registration rate of GPs gradually increased, and the total GP resources showed a continuous growth, but the ratio of GPs per 10 000 population was still unsatisfactory, great inter-region differences existed in the distribution of GP resources, and the equity of the distribution of GP resources by geography was more unsatisfactory than by demographics or economy.

Exploring the factors affecting health service utilization is of great significance for optimizing the allocation of health services. Health-related quality of life (HRQoL) focuses on individuals' subjective self-assessment of their current health status, and may affect their health-seeking behaviors, but there are few studies on the impact of HRQoL on health service utilization of rural residents in China.

To explore the relationship between HRQoL and health service utilization of rural residents in Ningxia Hui Autonomous Region, and to provide a reference for the development of relevant policies/plans, and for the optimization health services in rural areas.

Data were collected from the Health Survey of Rural Residents Families 2019 conducted in four sample counties of Ningxia (Haiyuan, Pengyang, Xiji, Yanchi) from July to August 2019, involving 9 310 cases (≥15 years) with complete key information (gender, age, HRQoL-related indicators, health service utilization indicators). Detailed data of the residents were extracted, including socio-economic and demographic characteristics, health services accessibility, prevalence of chronic diseases, HRQoL measured using European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L) and utilization of health services. The effects of health state utility values and visual analog scale (VAS) score on outpatient and inpatient health service utilization were analyzed by binary Logistic regression.

The utilization rates of outpatient and inpatient health services of rural residents in Ningxia were 10.85% (1 010/9 310) and 18.86% (1 756/9 310), respectively. The mean health state utility values and mean VAS score of them were (0.965±0.090) and (69.97±17.84), respectively. Difference testing showed that residents with impaired self-care (in the EQ-5D-3L descriptive system) had higher rates of using outpatient health services〔OR (95%CI) =3.197 (2.633, 3.883), P<0.001〕and inpatient health services〔OR (95%CI) =4.802 (4.059, 5.681), P<0.001〕compared with those with impaired mobility, usual activities, or higher level of pain/discomfort or anxiety/depression. Binary Logistic regression analysis showed that after adjusting for various confounding factors, health state utility values and VAS score were associated with the use of outpatient and inpatient health services (P<0.05). Moreover, the prevalence of chronic diseases also significantly affect the utilization of outpatient and inpatient health services (P<0.05) .

HRQoL and the prevalence of chronic diseases were leading factors affecting the utilization of outpatient and inpatient services in Ningxia rural residents. As an independent predictive factor of residents' health service utilization, HRQoL can be used to assist in the evaluation and monitoring of health service quality and effect, and provide guidance for rational allocation of health resources.

With the development of information technology, artificial intelligence shows great potentials for clinical diagnosis and treatment. Nevertheless, bias in algorithms derived by artificial intelligence can lead to problems such as unequal distribution of healthcare resources, which significantly affect patients' health equity. Algorithmic bias is a technical manifestation of human bias, whose formation strongly correlates with the entire development process of artificial intelligence, starting from data collection, model training and optimization to output application. Healthcare providers, as the key direct participants in ensuring patients' health, should take corresponding measures to prevent algorithmic bias to avoid its related health equity issues. It is important for healthcare providers to ensure the authenticity and unbiasedness of health data, optimize the fairness of artificial intelligence, and enhance the transparency of its output application. In addition, healthcare providers need to consider how to tackle bias-related health inequity, so as to comprehensively ensure patients' health equity. In this study, we reviewed the causes and coping strategies related to algorithmic bias in healthcare, with the aim of improving healthcare providers' awareness and ability to identify and address algorithmic bias, and laying a foundation for ensuring patients' health equity in the information age.

With the increasing aging and the transformation of the disease spectrum of residents, there is increasing national attention to the development of Traditional Chinese Medicine (TCM) services. It is of great significant in better utilizing the proper value of TCM community services in the future to understand the current situation and influencing factors of TCM community services utilization.

To understand the current situation and influencing factors of TCM community services utilization among residents in the main urban areas of Chongqing from demander's perspective, so as to provide reference for the sustainable development of TCM community services.

On December 1, 2021, 23 community health service centers were selected by quota sampling method in proportion to the population in 9 central urban areas of Chongqing, and the residents in each community health service center and its surrounding communities by incidental sampling method were selected to conduct questionnaire surveys. The actual number of questionnaires distributed was 840 with 806 valid questionnaires and effective rate of 96.0%. Based on Anderson's health service utilization behavior analysis framework, the factors influencing individual service utilization behavior were summarized into three categories: tendency characteristics, enabling resources and demand factors. At the same time, the dimension of personal TCM culture was added. Binary Logistics regression was used to analyze the influence of the four dimensions on the utilization of TCM in the community.

The utilization rate of TCM community services among the surveyed residents was only 35.9% (289/806), 12 indicators in 4 dimensions were associated with the TCM community services utilization, including propensity characteristics (age, marital status), enabling resources (type of medical insurance, medical expenditure in the last 2 weeks, whether the institutions can meet the basic medical needs of families, whether institutions provide TCM services), demand factors (chronic diseases, self-perception of physical condition in 2 weeks, demand for TCM community services), personal TCM culture (TCM referral willingness, TCM culture trust level, community TCM cultural atmosphere) (P<0.05) .

There are multidimensional and multifactorial influences on the TCM community services utilization among residents. Therefore, targeted measures should be taken to promote residents' utilization of TCM community services.

The increasing elderly floating people in China are prone to the risk of impaired health status and low utilization of public health services due to older age and unstable life. At present, there is a lack of research on income-related public health services utilization and health inequities in this population.

To understand the utilization of public health services and health status of elderly migrants, evaluate the utilization of public health services and health equities in them, and put forward suggestions for reducing income-related health inequalities.

In April 2022, elderly migrants aged 60 years or over (n=5 840) were selected from the China Migrants Dynamic Survey 2018 as the study population. Public health service utilization was assessed using the data related to the use of health education, health records and family doctor services. Health status was assessed based on self-rated health and morbidity in the past one year. Socio-demographic, economic and migrant characteristics were collected as explanatory variables. The Erreygers-corrected concentration index (EI) was used to measure income-related inequality in the utilization of public health services and health status. The decomposition analysis based on logit model was used to quantify the contribution of each determinant to total inequality.

Among the elderly migrants, the health education acceptance rate was 72.12% (4 212/5 840), with an EI of 0.021 (P>0.05). The rate of health record establishment was 30.99% (1 810/5 840), with an EI of -0.054 (P<0.05). And the rate of contracting a family doctor was 16.83% (983/5 840), with an of EI of -0.057 (P<0.05). Self-rated good health accounted for 82.29% (4 806/5 840), with an EI of 0.199 (P<0.05). The morbidity rate in the past one year was 29.02% (1 695/5 840), with an EI of 0.123 (P<0.05). The decomposition of EI results showed that per capita income had the highest percentage contribution to the equity of public health service utilization (74.354%, 53.383%), followed by geographic range of migration (43.474%, 32.063%). And per capita income also demonstrated the highest percentage contribution to health inequity (59.561%, 66.641%), followed by the impact of household registration on self-rated health (36.347%), and the impact of geographic range of migration on the morbidity (14.153%) .

Low-income older migrants are prone to low rate of public health service utilization and poor health outcomes. Income is the most important cause of public health service utilization inequity and health inequity among elderly migrants. Relevant departments should do a good job in publicizing public health services in this population, and give priority to those with a low economic status.

With the severe situation of the increasingly population aging in China, the health problems of the middle-aged and older adults can not be ignored, attracting much attention on the health equity among the rural-dewlling middle-aged and older adults. The geographic remoteness of southern mountainous area in the Ningxia Hui Autonomous Region causes the health conditions of the middle-aged and older adults more unoptimistic. However, there are relatively few studies on the health equity among the middle-aged and older adults in this area.

To investigate the health equity of the middle-aged and older adults in the pilot counties of medical reform in the Ningxia Hui Autonomous Region (Haiyuan County and Yanchi County) and analyze the contribution degree of various influencing factors to health inequality, so as to provide a basis for improving the health of the middle-aged and older adults and relevant health policies.

From January to March in 2022, from the follow-up data of 2019 from the Family Health Inquiry Survey of Rural Residents, the middle-aged and older adults (age≥45 years old) from resident families (living in the corresponding counties for more than one year) were selected as subjects (n=5 908) . The analysis was conducted with the two-week prevalence rate, chronic disease prevalence rate, two-week bedridden rate and two-week leaving rate as dependent variables, with sex, age, marital status, level of education, occupation, type of drinking water and per capita family income as independent variables. The concentration index was used to analyze the health equity of the middle-aged and older adults, and the centralized index decomposition method was used to analyze the contribution of various influencing factors to health inequality.

The concentration indexes of two-week prevalence rate, chronic disease prevalence rate, two-week bedridden rate and two-week leaving rate among the middle-aged and older adults in Haiyuan County were 0.030 0, 0.002 9, 0.011 4 and 0.032 7, respectively, while those of two-week prevalence rate, chronic disease prevalence rate, two-week bedridden rate and two-week leaving rate among the middle-aged and older adults in Yanchi County were 0.000 4, -0.000 1, 0.037 4 and 0.037 4, respectively. The concentration index decomposition analysis showed that gender, age, level of education, occupation, type of drinking water and per capita family income are the main causes for health inequality among the middle-aged and older adults, among which age and per capita family income contribute more to health inequality. The contribution ratio of age to the two-week prevalence rate, hronic disease prevalence rate, two-week bedridden rate and two-week leaving rate in Haiyuan County were -11.92%, -152.57%, -27.76% and 7.80%, respectively. The contribution ratio of age to the two-week prevalence rate, chronic disease prevalence rate, two-week bedridden rate and two-week leaving rate in Yanchi County were -334.79%, 1 117.94%, -45.45% and-25.44%, respectively. The contribution ratio of per capita family income to the two-week prevalence rate, chronic disease prevalence rate, two-week bedridden rate and two-week leaving rate among the middle-aged and older adults in Haiyuan County were 35.41%, -0.31%, 2.08% and 22.03%, respectively. The contribution ratio to the two-week prevalence rate, chronic disease prevalence rate, two-week bedridden rate and two-week leaving rate among the middle-aged and older adults in Yanchi County were 86.88%, -165.24%, 37.13% and 1.50%, respectively.

Overall, the health equity among the middle-aged and older adults in the pilot counties of the Ningxia Hui Autonomous Region is better but tilted towards those with higher incomes. Age contributes the most to health inequity among the middle-aged and older adults. The society should give higher priority to the middle-aged and older adults; Local primary health care institutions can increase the health awareness of the middle-aged and older adults by providing free health check-ups regularly and promoting health literacy to them. The health administration should adjust relevant health policies to better meet the health needs of the middle-aged and older adults and ultimately achieve health equity.

The primary care facilities in a region play a vital role in maintaining the health of the local residents as the gatekeeper. At present, there is a lack of research on the allocation of primary care resources in Tibet, a remote autonomous region in northwestern China.

To analyze the current situation and equity of the allocation of primary care resources in Tibet, to provide a scientific basis for optimizing the allocation of primary care resources in Tibet.

Data used in this study were from six volumes (2015—2020) of Tibetan Health Statistics Yearbook and China Health Statistics Yearbook, as well as the human resource information in the Primary Care Direct Reporting System of Tibet Health Commission from 2015 to 2020. Descriptive analysis was used to analyze the allocation of primary care resources in Tibet from 2015 to 2020. Gini coefficient and concentration index were used to evaluate the equity of primary care resource allocation in Tibet in 2020.

The number of beds in primary hospitals in Tibet increased from 3 393 in 2015 to 3 867 in 2020. The number of (assistant) practicing physicians per 1 000 people increased from 0.37 in 2015 to 0.61 in 2020. The utilization rate of beds in primary hospitals decreased from 30.9% in 2015 to 11.5% in 2020. The daily visits per primary care physician decreased from 13.80 in 2015 to 9.95 in 2020. The daily number of hospital bed days of care per primary care physician decreased from 0.44 in 2015 to 0.10 in 2020. In 2020, the Gini coefficients of health resources allocated in primary hospitals according to population in Tibet were greater than 0.3, which were better than those allocated according to geography. The difference in the concentration degree between number of beds, number of health technicians, number of (assistant) practicing physicians or number of registered nurses and population, was -6.93, -4.50, -2.50, -6.15, respectively, in Lhasa, and 0.05, -0.21, -0.80, -0.22, respectively, in Changdu, and -0.88, 0.10, 0.47, -0.05, respectively, in Shannan, but was all greater than 0 in other cities.

The primary health workers in Tibet showed a trend of "low growth in number, low capability and low efficiency". It is suggested to pay attention to regional characteristics to improve the allocation standards of primary care resources, promote the equity of the allocation of primary care resources based on geographical classification, reform the employment mechanism and human resource management system in primary care, innovate the system and mechanism of aiding Tibet and establish a new model of financial investment at the primary level.

The needs of outpatient services, a key accessible health resource, are increasing in an increasingly aging population in China. So rational allocation of outpatient service resources to meet older people's health needs is a key to improving their health level.

To explore the factors affecting the utilization of outpatient services in the elderly, to provide feasible suggestions for improving older people's health level and the allocation of medical resources.

This study was conducted in 2021 using the data of older people (≥60 years old) attending the CHARLS 2018. The number of using outpatient services in these people in the past month prior to the CHARLS 2018 and associated factors were studied using a system developed based on the framework of Anderson's Behavioral Model of Health Services Use, with sex, age, marital status, the type of hukou (rural or urban), education level, smoking and drinking were classified as predisposing factors, health insurance, monthly household income per capita and the average distance from home to medical institutions as enabling factors, and chronic disease prevalence and self-rated health as need factors. The zero-inflated negative binomial regression (ZINB) was used to identify factors associated with the use of outpatient services.

In all, 9 551 older people were included for analysis. Among them, non-users of outpatient services in the past month numbered 8 038 (84.16%), and one-time, two-time, and three or more-time users numbered 749 (7.84%), 367 (3.84%), and 397 (4.16%), respectively. The number of using outpatient services differed statistically by the type of hukou, education level, smoking, drinking, health insurance prevalence, monthly household income per capita, chronic disease prevalence, and self-rated health status (P<0.05). The results of Logit regression model (one part of the ZINB) in fitting the data indicated that older age, high school education or above, having health insurance, suffering from a chronic disease and poor self-rated health were associated with increased probability of utilizing outpatient services (P<0.05). And the results of negative binomial count model in fitting the data indicated showed that the age of 70-74 years was associated with decreased probability of utilizing outpatient services, while an average distance of greater than 1 km but less than 10 km between home and medical institutions, and three types of self-rated health (good, poor and very poor) were associated with increased probability of utilizing outpatient services (P<0.05) .

Our study indicates that the use of outpatient services was insufficient in these older people, which was associated with predisposing, enabling and need factors. To improve this, it is suggested to rationally strengthen the provision of outpatient services to vulnerable groups with underuse of such services and individuals with needs of high-quality services. In addition, attention should be given to chronic disease management and self-rated health of the elderly to improve their awareness and level of health management.

The high prevalence of multimorbidity among middle-aged and older adults has become a serious issue needing to be addressed by China's healthcare system. The number of chronic diseases is related to health service utilization and medical costs, but there is still a lack of relevant national surveys in China.

To understand the prevalence and features of multimorbidity and to examine its associations with health service utilization and medical costs among middle-aged and older Chinese adults.

Data were collected from the 2018 wave of China Health and Retirement Longitudinal Study (CHARLS) during April to October 2021, involving 16 674 Chinese adults (≥45 years old) . Multimorbidity was defined as the coexistence of two or more of the self-reported 14 chronic conditions. Health service utilization was measured using inpatient service utilization in the past year and outpatient service utilization in the past month. Medical costs were measured using total inpatient cost and out-of-pocket (OOP) cost for inpatient care in the past one year, total outpatient costs and OOP cost for outpatient care in the past one month. Logistic regression was used to estimate the association between the number of chronic diseases and health service utilization. Quantile regression was adopted to estimate the association between the number of chronic diseases and medical costs.

Of all participants, 9 561 (57.34%) had multimorbidity. 2 624 (15.74%) had utilized inpatient services in the past year, and 2 588 (15.52%) used outpatient services in the past one month. Inpatient service utilization, outpatient service utilization, total inpatient cost, OOP cost for inpatient care, total outpatient cost, and OOP cost for outpatient care varied significantly by the number of chronic diseases (P<0.05) . Multivariate Logistic regression analysis indicated that the number of chronic diseases was associated with inpatient service utilization (P<0.05) . Suffering from 1, 2, 3, 4 and ≥5 chronic diseases was associated with 1.882 times〔95%CI (1.547, 2.290) 〕, 2.939 times〔95%CI (2.429, 3.555) 〕, 4.231 times〔95%CI (3.490, 5.130) 〕, 5.723 times〔95%CI (4.680, 7.000) 〕, and 8.671 times〔95%CI (7.173, 10.482) 〕 higher rate of inpatient service utilization, respectively. Having 1, 2, 3, 4 and ≥5 chronic diseases was associated with 1.684 times〔95%CI (1.421, 1.995) 〕, 2.481 times〔95%CI (2.101, 2.931) 〕, 3.691 times〔95%CI (3.115, 4.374) 〕, 3.774 times〔95%CI (3.134, 4.544) 〕, and 5.577 times〔95%CI (4.698, 6.620) 〕 higher rate of outpatient service utilization, respectively. Each increased chronic disease was associated with an increase in both total inpatient costs and OOP for inpatient care at the upper and middle (50, 75 and 90 percentiles) percentile levels, with larger effects on the upper percentile 〔90th percentile Coeff (95%CI) =1 248.43 (219.20, 2 277.66) for total hospital costs; 90th percentile Coeff (95%CI) =706.36 (266.87, 1 145.86) for OOP for inpatient care〕. Each increased chronic disease was also associated with an increase in both total outpatient costs and OOP for outpatient care, and the effects on the upper percentiles were larger〔90th percentile Coeff (95%CI) =196.33 (31.06, 361.61) for total outpatient costs; 90th percentile Coeff (95%CI) =128.56 (26.83, 230.28) for OOP for outpatient care〕.

In middle-aged and older Chinese adults, multimorbidity was highly prevalent, and the increase in the number of coexisted chronic diseases was associated with higher rate of health service utilization and medical costs. The government should pay more attention on primary care to manage the demand for health services and medical costs associated with multimorbidity.