Health inequality aversion in China: Public and decision-maker views

Health policy aims not only to improve total population health but also to reduce social inequality in health. When these aims conflict, understanding how different stakeholders navigate equity-efficiency trade-offs is critical. This study compared patterns of health inequality aversion among the Chinese general population and health decision-makers. Data were collected from January to April 2025 in a national cross-sectional survey comprising 1001 members of the general population and 80 health decision-makers. Using the Benefit Trade-Off method, respondents evaluated hypothetical programs that improved quality-adjusted life expectancy across income groups. We quantified preferences by estimating inequality aversion parameters where possible and analyzing response distributions and deliberation times. Results show a clear divergence in preferences. The general population exhibited a strongly polarized bimodal pattern, with around one-quarter of respondents at the pro-rich polar extreme and a majority at a lexically egalitarian pro-poor polar extreme that lies beyond finite Atkinson-parameter estimation. By contrast, decision-makers were more likely to have weighted pro-poor ("prioritarian") preferences between these two polar extremes. These differences were not associated with demography, income, or education and decision-makers took substantially longer to complete the trade-off questions. The causes of this divergence are not known, but one potential explanation is that the public tend to focus on one main policy objective whereas decision-makers tend to recognize multiple conflicting policy objectives and seek a compromise. Given this systematic preference divide, institutional mechanisms that combine public participation with deliberative reflection may help reconcile efficiency and equity considerations in health priority-setting.