Effectiveness of outpatient financing reform from health savings accounts to pooling scheme in China: a systematic review

Outpatient services are fundamental to safeguarding population health and promoting the efficient use of healthcare resources. However, China has long faced limited risk pooling and inadequate financial protection for outpatient services. In 2021, China launched a nationwide outpatient financing reform to address these limitations. This study examines the effectiveness of this reform, which shifted outpatient financing from individual health savings accounts (HSAs) to an outpatient pooling scheme. A systematic search of PubMed, Web of Science, and Chinese National Knowledge Infrastructure (CNKI) was conducted for studies published between 1998 and December 2025. A total of 21 studies were included in this review. Overall, the reform was generally associated with increased outpatient utilization. Several studies suggested substitution between outpatient and inpatient care, whereas others indicated complementary effects. Findings on medical expenditure and out-of-pocket spending were mixed, while limited evidence suggested increased primary healthcare utilization and improved health-related behaviors. Overall, the effects varied across outcomes and policy settings, highlighting the importance of policy design and local healthcare contexts.