General Medicine · Medical Literature
Impact of government health expenditure on health outcomes in China: a quantitative analysis of mediation and threshold effects
Abstract
Objectives To investigate the impact of government health expenditure on health outcomes in China, including its direct effects, underlying pathways and how these effects vary under different conditions of expenditure scale, health resource availability and economic development. Design A quantitative study using provincial panel data from 2008 to 2023. Analysis was conducted using a fixed-effects model, with instrumental variables employed to address potential endogeneity. A mediation model was used to examine indirect pathways and a threshold regression model was applied to explore heterogeneous effects across different levels of key variables. Setting The study was conducted using data from Chinese provinces over the period 2008–2023, within the context of China’s national health policy and the ‘Healthy China’ strategy. Participants 31 provinces, autonomous regions and municipalities in China were included, with data extracted from official statistical yearbooks and health reports over the 16-year period. Primary and secondary outcome measures Primary outcomes: maternal mortality and perinatal mortality. Secondary outcome: life expectancy. Results Government health expenditure significantly reduced maternal mortality and perinatal mortality but its effect on life expectancy was not statistically significant. The number of health institutions showed a negative mediating effect. Threshold analysis revealed that the impact of government health expenditure varied across levels of expenditure scale, health resources and economic development. In low-income contexts, government health expenditure could even produce adverse effects; however, with improved economic development and greater health resource availability, its positive impact on health outcomes became increasingly evident. Conclusions The health effects of government health expenditure are highly context-dependent. Optimal policy effectiveness requires coordinated interaction among
Clinical relevance
This study addresses a critical gap in health policy evidence by quantifying how government health expenditure translates into measurable population health outcomes across China's 31 provinces over 16 years (2008–2023), a period encompassing major health system reforms including the 'Healthy China' strategy. It directly affects maternal and perinatal populations—groups particularly sensitive to health system investment—and provides granular evidence on why uniform spending increases may not yield uniform benefits. Clinicians and health system leaders should engage with these findings as they inform resource allocation decisions in heterogeneous economic and infrastructural contexts, including low- and middle-income settings globally.
Key findings
1. Government health expenditure was significantly associated with reductions in maternal mortality and perinatal mortality across Chinese provinces, though specific effect sizes and confidence intervals were not reported in the abstract. 2. The effect of government health expenditure on life expectancy was not statistically significant, suggesting that expenditure alone may be insufficient to drive gains in this broader outcome measure. 3. The number of health institutions demonstrated a negative mediating effect on the relationship between government health expenditure and health outcomes, indicating that expansion of health infrastructure partially attenuates or modifies the direct expenditure-outcome pathway. 4. Threshold regression analysis identified nonlinear, heterogeneous effects: the impact of government health expenditure varied across levels of expenditure scale, health resource availability, and economic development. 5. In low-income provincial contexts, government health expenditure was associated with adverse effects on health outcomes, suggesting a threshold below which spending may be counterproductive or misdirected. 6. Above thresholds of greater economic development and higher health resource availability, the positive impact of government health expenditure on health outcomes became increasingly pronounced, consistent with a multiplicative or synergistic policy environment. NOTE: Precise quantitative values (effect sizes, CIs, p-values, NNT/NNH) were not available in the provided abstract; findings are reported as described therein.
Practice implications
Health system administrators and policymakers should resist treating government health expenditure as a uniformly effective lever: in low-income or resource-scarce provincial or regional contexts, increased spending without concurrent investment in health infrastructure and economic development may yield negligible or even harmful outcomes, and targeted capacity-building must precede or accompany expenditure scale-up. Maternal and perinatal health programs represent the highest-yield targets for government health investment, warranting prioritization of these populations in budget allocation decisions, particularly in regions crossing identified economic and resource thresholds. Mediation through health institution density underscores the importance of monitoring not just expenditure volume but downstream structural outputs—clinicians involved in health system planning should advocate for integrated metrics that track both financial inputs and institutional capacity as co-dependent indicators of policy success.