Qin, Vicky MengqiVicky MengqiQinZhang, YutingYutingZhangChia, Kee SengKee SengChiaMcPake, BarbaraBarbaraMcPakeZhao, YangYangZhaoHulse, EmilyEmilyHulseLegido-Quigley, HelenaHelenaLegido-QuigleyLee, John TayuJohn TayuLee2026-04-022026-04-022020-06-17https://scholars.lib.ntu.edu.tw/handle/123456789/737020Objectives Understanding the variation in user fees is essential for the design of targeted health financing strategies and monitoring progress towards universal health coverage. This study examines user fees in terms of: (1) temporal trends in cost sharing and out-of-pocket payment (OOPs); (2) factors associated with cost sharing and OOPs; and (3) the relationships between province-level economic development and cost sharing and OOPs in China. Setting 28 provinces of China Participants A total of 10316 elderly aged ≥45 years were included in the analysis. Results Overall, there were no substantial changes in cost sharing, but the OOPs continued to rise among the middle-aged and older Chinese. Cost sharing was substantially higher for outpatient than inpatient care (84.0% vs 69.2% in 2011; 80.8% vs 62.2% in 2015), and the majority paid more than 80% of the total cost for prescription drugs when visiting outpatient or inpatient care. Provinces with higher GDP per capita tend to have lower cost sharing and a higher OOPs than their counterparts, but the relationship for OOPs became insignificant after adjusting for individual factors. Respondents with health insurance and older age were associated with lower cost sharing. The respondents with higher socioeconomic status and a higher number of chronic conditions incurred higher OOPs for outpatient and inpatient utilisation. Conclusion Cost sharing and OOPs remain very high despite near-universal insurance coverage. Health financing reforms should prioritise improving health services coverage and reducing cost sharing to improve financial protection and reduce health inequalities. Although such improvement will likely have the greatest benefits for financial protection for populations from less developed regions, developed provinces with a higher OOPs will benefit as well.enpreprint10.1101/2020.06.15.20131813