Background: Catastrophic health expenditure (CHE) is an important indicator for measuring health inequality. Previous studies mainly focused on whole populations rather than specific vulnerable groups through the regional survey or cross-sectional data. China’s rural area is often associated with an underdeveloped economy and insufficient health resources. This study aims to update the information on the extent and trends in incidence and inequality of CHE among the households of rural China through longitudinal survey data. Methods：Data were obtained from three waves of the China Health and Retirement Longitudinal Study (CHARLS): 2013, 2015, and 2018. CHE was defined as the proportion of household health expenditures to the non-food expenditure more than 40% threshold. The inequality of CHE was measured by the concentration index. Decomposition methods were used to decompose the concentration index into its determining components. Results：The incidence of CHE was 23.41% (95% CI: 0.22, 0.25) in 2013, 21.36% (95% CI: 0.20, 0.23) in 2015 and 28.97% (95% CI: 0.27, 0.31) in 2018 in rural households. The concentration index was negative: -0.1528 (95% CI: -0.1941, -0.1115) in 2013, -0.1010 (95% CI: -0.1442, -0. 0577) in 2015 and -0.0819 (95% CI: -0.1170, -0.0467) in 2018. Economic status, age, and chronic disease were the main contributors to the inequality of CHE. Conclusions：The incidence of CHE in rural households of China displayed an upward trend. Furthermore, there existed a strong pro-poor inequality of CHE in rural China. Economic status, age, and chronic diseasewere the main contributors to the pro-poor inequality. Health policies to allocate resources and services are needed to satisfy the needs of rural households and provide more accessible and affordable health services. More concerns need to be directed toward households with chronic diseases and households with the elderly. Meanwhile, policymakers need to pay more attention to relieving the incidence of CHE and promoting health equality.

Background: Catastrophic health expenditure (CHE) is an important indicator for measuring health inequality. Previous studies mainly focused on whole populations rather than specific vulnerable groups through the regional survey or cross-sectional data. China’s rural area is often associated with an underdeveloped economy and insufficient health resources. This study aims to update the information on the extent and trends in incidence and inequality of CHE among the households of rural China through CHARLS panel data. Methods：Data were obtained from three waves of the China Health and Retirement Longitudinal Study (CHARLS): 2013, 2015, and 2018. CHE was defined as the proportion of household health expenditures to the non-food expenditure more than 40% threshold. The inequality of CHE was measured by the concentration index. Decomposition methods were used to decompose the concentration index into its determining components. Results：The incidence of CHE was 23.41% (95% CI: 0.22, 0.25) in 2013, 21.36% (95% CI: 0.20, 0.23) in 2015 and 28.97% (95% CI: 0.27, 0.31) in 2018 in rural households. The concentration index was negative: -0.1528 (95% CI: -0.1941, -0.1115) in 2013, -0.1010 (95% CI: -0.1442, -0. 0577) in 2015 and -0.0819 (95% CI: -0.1170, -0.0467) in 2018. Economic status, age, and chronic disease were the main contributors to the inequality of CHE. Conclusions：The incidence of CHE in rural households of China displayed an upward trend. Furthermore, there existed a strong pro-poor inequality of CHE in rural China. Economic status, age, and chronic diseasewere the main contributors to the pro-poor inequality. Health policies to allocate resources and services are needed to satisfy the needs of rural households and provide more accessible and affordable health services. More concerns need to be directed toward households with chronic diseases and households with the elderly. Meanwhile, policymakers need to pay more attention to relieving the incidence of CHE and promoting health equality.