Public values for drug reimbursement priority setting in China’s basic medical insurance system: a qualitative study

Background Equitable priority setting for publicly financed medicines is a central challenge for health systems pursuing universal health coverage. In China, the Basic Medical Insurance (BMI) system faces mounting pressure to make transparent and socially legitimate drug reimbursement decisions. This study aimed to explore public values and the rationales underlying priority-setting criteria for BMI drug reimbursement. Methods Semi-structured interviews were conducted across three phases with 17 purposively sampled participants from four geographically diverse Chinese cities. A literature- and expert-informed interview guide combined open-ended and interviewer-prompted discussion, with ranking tasks in later phases and hypothetical prioritization exercises in the final phase. The original Chinese transcripts were analyzed using open coding and constant comparison in NVivo 14 to develop categories and themes. Final codes, theme labels and selected quotations were translated into English. Results Participants strongly emphasized prioritizing medicines that benefit broad population groups, reflecting the BMI system’s basic protection mandate and concerns about societal economic burden and productivity loss. Severe conditions, defined mainly by lethality and treatment urgency, emerged as a major priority and were often discussed alongside high treatment costs, family financial hardship and the risk of medical impoverishment. Therapeutic efficacy was viewed as a baseline requirement, while curative potential was regarded as an important supplementary criterion. Low-income individuals and rural residents were frequently endorsed as deserving priority, often following interviewer prompting, because of their vulnerability and limited healthcare access. Age-related prioritization elicited divergent views, although the largest subgroup favored medicines for children because of their future life opportunities, family significance and potential societal contributions. When prompted to consider drug origin, participants often preferred domestically produced medicines when effectiveness and cost were similar, although origin was not viewed as a critical reimbursement criterion. Conclusions In this study, participants’ accounts suggested that considerations relevant to drug reimbursement extended beyond conventional efficiency to include population benefit, disease severity, financial protection, curative potential and support for vulnerable groups. These exploratory qualitative findings identify values and rationales that may inform further public engagement and quantitative research on more transparent, equity-sensitive and socially legitimate drug reimbursement processes under China’s BMI system. Trial registration Not applicable.