Does the hierarchical medical system enhance healthcare utilization and equity in China? a longitudinal study 2012–2018

HMS had an unintended impact on decreasing healthcare utilization in China. HMS improved equity in outpatient utilization, it faced challenges in enhancing equity in inpatient utilization. Policymakers should prioritize strengthening primary care infrastructure in central and rural areas, ensuring affordable healthcare models, reinforcing educational attainment, and expanding health insurance coverage to promote equity in healthcare utilization. These findings provide crucial insights for guiding equitable healthcare reform in LMICs and advancing progress toward the Sustainable Development Goals.