Beyond healthcare needs: income-related inequality in healthcare utilization among urban and rural residents in Jiangsu, China

Reducing income-related inequality in healthcare utilization remains a critical public health challenge in China, especially given the rapid population aging and the increasing burden of chronic diseases. This study aimed to evaluate income-related inequality in healthcare utilization among urban and rural respondents of the 2023 Jiangsu National Health Service Survey (NHSS) and to identify factors contributing to the observed disparities. Data for this study were obtained from the seventh Jiangsu Provincial NHSS conducted in 2023. The analytical sample consisted of 9,330 respondents, of whom 4,245 were urban residents and 5,085 were rural residents. The concentration index (CI) was employed to measure income-related inequality in healthcare utilization separately for urban and rural populations. Furthermore, decomposition of the CI was conducted to quantify the respective contributions of various factors to the identified inequalities. Within the analytical sample, healthcare utilization patterns differed between urban and rural respondents. Urban respondents reported a slightly higher proportion of two-week outpatient utilization (10.79% vs. 9.64%), whereas rural respondents reported a higher proportion of hospitalization in the preceding year (12.70% vs. 7.73%). Income-related inequalities in healthcare utilization among urban residents were minimal (CI for outpatient visit frequency = − 0.0221; CI for hospitalization days = − 0.0057), and neither CI was statistically significant. In contrast, a non-significant pro-rich pattern was observed in inpatient service utilization among rural residents (CI = 0.0454, P = 0.063); after need standardization, the CI was 0.0559 ( P = 0.016), indicating statistically significant pro-rich inequality. Decomposition analysis further revealed that enabling factors (109.43%) contributed the most to rural inpatient inequality overall, particularly household consumption expenditure (125.84%) and insurance-related factors, whereas need factors (− 15.59%) showed an overall equalizing contribution. In addition, primary care and prevention-related variables, such as family doctor contracting and health check-ups, exhibited decomposition contributions that were associated with the observed distributional patterns. Within the analytical sample, hospitalization days among rural respondents exhibited a non-significant pro-rich pattern before need standardization but a statistically significant pro-rich inequality afterward, whereas the corresponding CIs for urban residents remained near zero. Decomposition results indicated that the observed rural inpatient inequality was more strongly associated with economic and access-related factors than with healthcare needs. Primary care and prevention-related variables—including family doctor contracting status and health check-ups—demonstrated distributional associations that were potentially equity-favorable. These findings suggest that strengthening primary care and implementing targeted financial protection measures represent promising policy directions for addressing income-related inequality in rural inpatient utilization.