Using tiered accreditation and decentralized governance to achieve population-based equity in pulmonary and critical care medicine in the Chinese mainland

Pulmonary and critical care medicine has become essential for managing severe respiratory conditions, yet many countries struggle to expand such services equitably across regions. Since 2018, the Chinese mainland has pursued a national strategy to establish specialized pulmonary and critical care departments using flexible accreditation standards that allow hospitals to progress at differently based on local capacity. The extent to which this approach has achieved equitable distribution remains unknown.

We analyzed data from 31 provincial-level regions in the Chinese mainland from 2018 to 2023, from the national pulmonary and critical care registry, health statistical yearbooks, and census databases. We assessed distribution equity using Lorenz curves, Gini coefficients, and a newly developed density index that accounts for both population and geographic area. Geographical Detector analysis was used to assess socioeconomic and institutional factors associated with spatial disparities.

Here we show that the number of pulmonary and critical care departments increases by 470.9% (from 409 to 2335), with the fastest growth occurring in underserved regions. Population-based equity improves (Gini coefficient decreasing from 0.288 to 0.169). However, geographic disparities remain severe (Gini: 0.644), particularly in western provinces. Factors showing the strongest spatial correspondence with these disparities include government health expenditure, public hospital availability, and interactions between economic development and administrative capacity. Workforce ratios (nurse-to-physician: 1.96) remain below international benchmarks.

The tiered accreditation model implemented in the Chinese mainland demonstrates that flexible, decentralized implementation can achieve rapid and population-equitable expansion of specialized medical services. These findings offer transferable principles for other countries seeking to balance national standardization with local adaptability, though addressing persistent geographic disparities and workforce shortages requires attention.