Ensuring healthy lives and promoting well-being for all individuals at all ages is one of the 17 Sustainable Development Goals (SDG). In recent years, considerable advances have been made in improving population health (1). For example, the global life expectancy at birth increased from 66.8 years in 2000 to 73.1 years in 2019, showing a steady increase from the turn of the millennium until the onset of the COVID-19 pandemic (2). At the same time, universal health coverage (UHC)—which ensures that all people can access the full range of quality health services they need, when and where they need them, without financial hardship (3)—has been widely recognized as a critical pathway for improving health outcomes (2). Strengthening health systems and enhancing the sustainability and equity of health services and financing models are thus pivotal for achieving UHC (2).

Despite the crucial role of health systems in improving health outcomes, the uneven distribution of health resources and inequalities in health accessibility and financial risk protection may further widen health disparities. According to the WHO’s analytical framework on priority public health conditions, when health systems deliver services that are less effective or inappropriate for disadvantaged groups, the impact of other social determinants on health outcomes and inequalities may be amplified (4). For instance, in the United States, poorer populations continue to face worse access to care than wealthier groups, partly because many remain uninsured despite the coverage expansions introduced under the Affordable Care Act (ACA) (5). In England, the National Health Service (NHS) has achieved substantial reductions in socioeconomic inequalities in primary care access and quality, yet progress in narrowing inequalities in health outcomes has been modest (6). Globally, efforts to achieve universal health coverage (UHC) have increasingly focused on strengthening health systems as a means to reduce disparities in both access to care and health outcomes (7, 8).

Although the health system provides this institutional context, its effectiveness ultimately depends on how individuals perceive and interact with it. According to the Lancet Global Health Commission on High-Quality Health Systems in the Sustainable Development Goals Era (HQSS), health systems should be judged primarily on their impacts, including improved health and its equitable distribution, public confidence in the health system, economic benefits, and processes of care (9). A high-quality health system offers people a sense of security—or confidence—that they or their family members will receive effective care in case of illness (10). Confidence in the health system is defined as the belief that people can get the healthcare they need if they “become very sick tomorrow” (10). More specifically, it refers to whether individuals in a country are confident that they can obtain and afford good-quality care if they are very sick (11), which represents both the subjective dimension of system performance within the WHO health system framework and an expanded understanding of universal health coverage. This concept has become increasingly important in health policy debates in high-income countries (12) and has more recently attracted attention in low- and middle-income countries (LMIC); however, the evidence remains comparatively limited (10, 13, 14).

As LMICs try to build public support and funding for UHC, research on population confidence in health systems has become particularly important. In addition to understanding the state of confidence in populations, it is essential to examine how confidence relates to the quality of healthcare processes, health outcomes, and the economic benefits of high-quality care (10). Previous research has investigated the extent of confidence in health systems (10, 11) and identified its determinants (14). Building on this foundation, it’s associations with healthcare utilization (15), health insurance enrollment (13), and health status (16), have been explored. These findings suggest that confidence reflects both the supply of health policies and individuals’ experiences, and that it can shape health-seeking behavior and influence outcomes. However, much of this work has focused on service use and insurance coverage, leaving the direct relationship between health system confidence and population health outcomes underexplored.

This gap is particularly salient in low- and middle-income settings, characterized by ongoing health system reforms and persistent structural challenges. China provides a relevant case for such investigation. As a developing country, it has undertaken extensive health reforms in recent years and has achieved notable improvements in population health. Yet, our understanding of how much confidence people have in China’s health system remains limited. Moreover, the association between health system confidence and individuals’ self-reported health warrants further investigation.

Over the past two decades, China has implemented a series of health policy reforms aimed at ensuring equitable and affordable access to quality basic healthcare and providing adequate financial protection (17, 18). Regarding financial risk protection, China achieved universal health insurance coverage (UHIC) by establishing three major social insurance programs: the Urban Employee Basic Medical Insurance (UEBMI, 1998), the New Rural Cooperative Medical Scheme (NRCMS, 2003), and the Urban Resident Basic Medical Insurance (URBMI, 2007). Since 2011, these programs have covered more than 95% of the population. In 2009, the Opinions of the CPC Central Committee and the State Council on Deepening the Health Care System Reform were released to advance the goal of universal access to basic healthcare services and to improve population health. Later, in 2016, the government launched the “Healthy China 2030 Plan,” a national strategy emphasizing equitable, accessible, systematic, and sustainable health services for all (19). During this period, health investment increased considerably, and health expenditure as a share of GDP increased from 5.03% in 2009 to 7.91% in 2023. Simultaneously, the personal health expenditure shared as percentage of total health expenditure declined from 37.46 to 27.33% (20). However, despite rapid policy reforms and rising health investment, China’s pronounced regional disparities mean that resources remain unevenly distributed across areas and population groups (21–24). Consequently, inequalities in health outcomes have become a central concern (25–29).

Building on the concept of health system confidence, this study was conducted with an aim to examine its association with health outcomes in China, with a particular focus on regional disparities. Specifically, we addressed three questions: (1) what are the levels of health system confidence and self-rated health across different regions of China, including urban–rural and east–central–west areas; (2) what is the relationship between confidence in the health system and self-rated health; and (3) do these associations vary across regions?

By addressing these questions, this study contributes to the growing literature on health system confidence in developing countries and provides evidence regarding the impact of this indicator on health outcomes. Furthermore, it identifies priority groups that should be targeted by policies aimed at reducing health inequalities and improving overall population health. Insights from this study may serve as a reference for other LMICs seeking to strengthen equity in their health security systems (30).

This study examined the association between confidence in health system and self-rated health (SRH) in China, with a particular focus on regional differences. The three main findings that emerged deepen our understanding of health system confidence and provide insights for health policy development in developing countries.

First, the overall confidence in the health system remains relatively low and exhibits substantial regional variation. Fewer than 20% of respondents across regions reported being somewhat or very confident in their ability to obtain and afford needed care if they became ill. This aligns with previous studies on health system confidence in China (10, 14), which have highlighted persistent public concerns about the reliability and fairness of health policy and resource distribution. When comparing different dimensions of confidence, we found a pattern which is consistent with cross-national evidence that shows affordability tends to generate weaker confidence than accessibility (11). The low reported confidence in obtaining and affording care suggests that the existing health insurance does not cover the desired services or that covered services do not meet people’s quality expectations (11). Moreover, regional analysis revealed that residents in western and rural areas consistently reported lower levels of confidence. These results indicate that despite the achievement of universal insurance coverage and improvements in financial protection, people in China continue to face concerns regarding financial barriers and service quality. Thus, they still face a high incidence of catastrophic expense together with the unequal health policy development and health resource distribution in subnational areas (21–24, 31).

Secondly, higher confidence in the health system is positively associated with better SRH, with the effect of affordability-related policies being particularly pronounced. This result is similar to a previous study which showed that financial protection and perceived quality play significant roles in determining public perception, whereas accessibility has limited influence on people’s perception of people’s perception of China’s health system (31). Thus, equitable access to basic primary healthcare services is a key step in establishing a tiered healthcare system for all (24), which is also a fundamental human right and a pillar of a country’s sustainable development (32). Moreover, financial protection policies, such as health insurance, reduce the risk of illness-induced poverty. Both accessibility and affordability can encourage healthcare utilization and ultimately improve health outcomes. More importantly, the combination of accessibility and affordability must be noticed. Although health services are available, they may not translate into improved health outcomes unless they are also affordable to patients. In addition, whereas the expansion of benefit package in the domain of financing is indeed a decisive move toward universal health coverage, the essential financial protection of the poor cannot be achieved without strong and coordinated supply-side reforms that target cost containment (33).

Finally, the positive association between confidence in the health system and SRH is particularly pronounced in disadvantaged regions, such as the western and rural areas. This pattern aligns with prior studies which showed that health insurance integration confers more benefits on vulnerable groups, including older adults, rural residents, and rural-to-urban migrants (34). One possible explanation is that these disadvantaged regions face inherently weaker health resources, which makes additional resource investment and institutional support more impactful. Although the China health insurance system covers more than 95% of the residents, there are certain groups—such as migrants, informal sector workers, and some rural residents—that remain excluded or are intermittently enrolled owing to increasing premiums. Besides, the benefits are unevenly distributed among different areas or between the labor sector and non-workers. For instance, according to the National Healthcare Security Administration, in 2024, the hospitalization reimbursement rate reached 84.8% under employee health insurance but only 68.6% under resident insurance (35). From the perspective of diminishing marginal returns, policy interventions and resource allocations frequently yield greater health benefits when directed toward resource-constrained regions and vulnerable populations. These results highlight the need for equity-oriented policies that explicitly prioritize disadvantaged groups.

The results of this study reveal future directions for further improving China’s health system and the other developing countries. First, given the overall low confidence in the health system—particularly regarding affordability—it is imperative to strengthen the health system as a whole, and achieving truly universal health insurance coverage should be prioritized. With equitable access being one of the main priorities of the health insurance, more efforts will be required to reach the poorest groups (13). In practice, this means that policies promoting insurance reimbursement in under-resourced regions should be carefully designed to ensure that vulnerable groups are not left behind.

In addition, since confidence in both accessibility and affordability are associated with better health outcomes, combining accessibility improvements with affordability safeguards could yield synergistic benefits, which can increase the health status of the entire population and reduce health inequality among different regions. For example, China’s policy of immediate reimbursement for cross-regional treatments helps the floating population achieve access to care while reducing their financial burden, and thereby addresses both accessibility and affordability dimensions to narrow health disparities (36). Additionally, continued reforms to hospital incentives and integrated delivery systems are critical for controlling health expenditures and enhancing healthcare quality (31).

Finally, the heterogeneous association between health system confidence and SRH across regions highlights the importance of spatially targeted health investments. This indicates that health policies should be implemented in different areas according to local resources and health needs. More importantly, these efforts should especially target to vulnerable groups. In western and rural areas, strengthening primary healthcare services and ensuring universal social protection coverage should be prioritized, complemented by financial transfer subsidies to bridge regional gaps. In contrast, eastern and urban regions could focus on reducing government responsibility while encouraging diversified, market-based healthcare investments.

Despite the insights gained from this study, it is important to acknowledge its limitations. First, owing to data constraints, we relied on mixed cross-sectional rather than panel data, and this limits causal inference (16) and prevents an analysis of how health policy reforms affect the same groups over time. In addition, our measures of confidence in accessibility and affordability, as well as SRH, were based on brief survey questions and reflect subjective perceptions; thus, a more precise measurement may consist of various questions related to health system confidence (15). Finally, the mechanisms through which confidence influences SRH remain insufficiently understood. Although we identified associations and heterogeneity, further research is needed to clarify the pathways linking confidence to health outcomes, including the role of contextual, behavioral, and institutional factors. Longitudinal studies of specific groups or regions, as well as refined classifications of health system types, would strengthen the understanding of these dynamics and provide a more reliable basis for policymaking under regional disparities.

This study examined the association between confidence in the health system and SRH from a regional comparative perspective. We found that overall confidence in the health system was relatively low and varied significantly across regions, with the lowest levels observed in western and rural areas. Higher levels of confidence were positively associated with better SRH, particularly when related to affordability, and this association was strongest in disadvantaged regions. These findings suggest that policies enhancing both affordability and accessibility are critical for improving population health and reducing regional inequalities. Targeting vulnerable groups with equity-oriented reforms should be prioritized to strengthen confidence in the health system and to advance health equity.