Critical care resource disparities in China: a nationwide survey and policy recommendations for health equity.

backgroundCritical care medicine plays a pivotal role in addressing life-threatening conditions; however, its development in China is hindered by resource scarcity and inequitable distribution. Existing studies have mostly focused on ICU bed numbers or selected regions, and have rarely provided a comprehensive, nationwide assessment of ICU beds, staffing and equipment using standardized methods, nor have they systematically quantified population-based equity of ICU resources. To address this evidence gap and describe the current landscape of critical care capacity in China, we conducted a nationwide survey of critical care resources. The survey aimed to describe the current status of resources, quantify population-based equity, and explore regional and hierarchical disparities that may affect access to critical care.

methodsThis cross-sectional survey was conducted from January 1, 2021, to December 31, 2023, encompassing public comprehensive hospitals, private hospitals, and specialty hospitals across 31 provinces (including municipalities) in China. A total of 4,744 hospitals with a comprehensive ICU provided valid responses and were included in the analysis; the overall response rate among eligible hospitals invited through provincial health authorities was approximately 89.80%. The study focused on institutions with comprehensive intensive care units (ICUs). Hospitals were stratified by level, including tertiary A and B, secondary A and B, and county-level hospitals. Data were collected using the “Critical Care Medicine Resource Survey Form” via Wenjuanxing, an online survey platform. The survey evaluated spatial distribution (bed count and density), equipment availability (ventilators, ECMO, and CRRT), and human resources (staffing and qualification disparities). Responses were analyzed to identify regional and hierarchical variations in resource allocation and utilization.

findingsAmong the 4,744 hospitals, there were 83,632 operational ICU beds, corresponding to a national average of 5.95 ICU beds per 100,000 population. The total ICU workforce comprised 46,137 physicians (a physician-to-bed ratio of 0.55:1) and 134,056 nurses (a nurse-to-bed ratio of 1.60:1). Key equipment included 74,842 invasive ventilators, 13,389 non-invasive ventilators, 2,328 ECMO devices and 12,346 CRRT machines. ICU bed density varied from 2.29 to 10.53 beds per 100,000 population across provinces. The Gini coefficients for ICU beds, physicians and nurses allocated by population were all < 0.2, and there were no statistically significant differences in ICU beds or physician numbers per 100,000 population across provincial GDP or GDP per capita tiers. From 2015 to 2023, ICU beds increased by 80.0%, physicians by 73.4%, nurses by 61.5%, and ECMO devices by 512.8%. Although population-based distribution appeared relatively equitable, regions differed in absolute bed density, staffing ratios and geographic accessibility, and advanced technologies such as ECMO were available in 29.2% of hospitals.

interpretationDespite remarkable progress and optimization in ICU resource expansion, substantial gaps remain in China compared to developed countries, particularly regarding ICU bed densities and staffing ratios. Our analysis indicates relatively equitable distribution of ICU beds, physicians and nurses across provinces when assessed on a per population basis, as reflected by low Gini coefficients, but this population-based equity does not account for differences in disease burden, age structure, urban-rural composition or geographic accessibility. Accordingly, population-based equity of resources does not necessarily imply equity of access or adequacy of care. Moreover, this survey focused on resource quantity and did not assess perceived adequacy, organizational models or clinical outcomes, so no direct conclusions can be drawn about quality of care.These findings suggest that efforts to strengthen critical care in China should focus on improving resource density and staffing in underserved regions, enhancing accessibility in geographically vast areas, and promoting efficient use and regional sharing of advanced technologies such as ECMO through organized referral networks.