Threshold associations between governance integrity and public satisfaction with government health coverage: evidence from the 2019 and 2021 China social surveys

While the government plays a pivotal role in the health security system, governance integrity is crucial for achieving Universal Health Coverage (UHC). Higher governance integrity is associated with enhanced effectiveness, equity, and positive perceptions of social security protection, resulting in increased public satisfaction with government health coverage—an essential indicator of health system performance. Over the past decade, China has implemented significant reforms to strengthen its health system and governance, moving closer to the goal of UHC. This study investigates the factors influencing public satisfaction with government health coverage, highlighting the critical role of governance integrity. It analyzes variations in satisfaction across socioeconomic groups, health insurance types, and urban and rural populations. This study utilized nationally representative datasets from the 2019 and 2021 Chinese Social Surveys (CSS) ( N = 17989) to analyze the associations between public satisfaction with government health coverage and governance integrity level, controlling for demographic variables. Ordered logistic regression models were employed to examine these associations, incorporating interaction terms to explore heterogeneous patterns across socioeconomic status, health insurance type, and urban-rural residency. Respondents residing in high-integrity areas demonstrated a significantly higher likelihood of reporting satisfaction with government health coverage (OR = 1.433, p < 0.001) compared to those in low-integrity areas, while the medium-integrity areas showed no significant association. In high-integrity areas, the socioeconomic gradient in satisfaction diminished considerably, with only the lower-middle class (OR = 0.467, p = 0.053) and the lowest class (OR = 0.316, p = 0.004) remaining significantly less satisfied. Furthermore, at high-integrity levels, respondents reported significantly higher satisfaction ratings regardless of the type of health insurance they held (OR > 1, p < 0.001). Finally, in these high-integrity regions, both urban (OR = 1.517, p < 0.001) and rural residents (OR = 1.311, p = 0.002) reported significantly higher odds of satisfaction, with a larger increase observed among urban respondents. This study reveals that high governance integrity is strongly linked to higher public satisfaction with government health coverage and the advancement of Universal Health Coverage (UHC). A threshold effect indicates that governance integrity must reach a high level to be associated with substantially higher satisfaction. This pattern aligns with the design strengths of the health insurance system, but it also widens the urban–rural satisfaction gap, as urban residents experience greater gains than rural residents. The findings of this study provide valuable empirical support for policymaking in China’s ongoing health reform and in other emerging economies where governance quality remains a binding constraint.