Analysis of satisfaction about new cooperative medical scheme and its influencing factors in Weihai, China

The old age health security in rural China: where to go?

Introduction

The huge number of rural elders and the deepening health problems (e.g. growing threats of infectious diseases and chronic diseases etc.) place enormous pressure on old age health security in rural China. This study aims to provide information for policy-makers to develop effective measures for promoting rural elders’ health care service access by examining the current developments and challenges confronted by the old age health security in rural China.

Methods

Search resources are electronic databases, web pages of the National Bureau of Statistics of China and the National Health and Family Planning Commission of China on the internet, China Population and Employment Statistics Yearbook, China Civil Affairs’ Statistical Yearbook and China Health Statistics Yearbooks etc. Articles were identified from Elsevier, Wiley, EBSCO, EMBASE, PubMed, SCI Expanded, ProQuest, and National Knowledge Infrastructure of China (CNKI) which is the most informative database in Chinese. Search terms were “rural”, “China”, “health security”, “cooperative medical scheme”, “social medical assistance”, “medical insurance” or “community based medical insurance”, “old”, or “elder”, “elderly”, or “aged”, “aging”. Google scholar was searched with the same combination of keywords.

Results

The results showed that old age health security in rural China had expanded to all rural elders and substantially improved health care service utilization among rural elders. Increasing chronic disease prevalence rates, pressing public health issues, inefficient rural health care service provision system and lack of sufficient financing challenged the old age health security in rural China.

Conclusions

Increasing funds from the central and regional governments for old age health security in rural China will contribute to reducing urban–rural disparities in provision of old age health security and increasing health equity among rural elders between different regions. Meanwhile, initiating provider payment reform may contribute to improving the efficiency of rural health care service provision system and promoting health care service access among rural elders.

Does China's new cooperative medical scheme promote rural elders' access to healthcare services in relation to chronic conditions?

BACKGROUND

This study examined use of healthcare services by elderly people with a long-term condition living in rural China and participating in that country's New Cooperative Medical Scheme (NCMS).

METHODS

Data were taken from the 2009 China Health and Nutrition Survey.

RESULTS

The study results showed that education level and annual income were low among rural elders (aged ≥65 years); the illiteracy rate was 58.0% (200/345) and 67.6% (92/136) had an annual income of less than 5000 Chinese yuan renminbi. The elders had low rates of treatment and use of preventive healthcare services while the prevalence of chronic disease was highest among them when compared to other age groups. Among the few elders who received preventive healthcare, most received it at village clinics.

CONCLUSIONS

Preventive healthcare services and chronic disease management are urgently needed by rural elders in China. NCMS should initiate payments to township health centers to enable them to undertake community outreach and education campaigns among rural residents, and train village doctors in standard chronic condition management and prevention, with prioritization of the provision of prevention and management of chronic conditions by village clinics.

Will China's Cooperative Medical System fail again? Insight from farmer satisfaction survey

This paper studied the sustainability of China's New Rural Cooperative Medical System (NCMS) by evaluating the satisfaction rate of its participants-the farmers. The study related the overall satisfaction of the farmers to their satisfaction with the four different aspects of the program. It also identified which personal and program attributes affect the farmers' satisfaction rate. Survey data of 1278 households from 66 counties in Shandong Province of China were collected in 2011 using a multi-stage stratified cluster-sampling method. To overcome the nepotistic barriers in rural China, field surveys in each township were conducted by university students from the same place. Data were analyzed using multiple regressions and structural equation modeling method. The results showed that 86% of the farmers were either satisfied or very satisfied with the NCMS and 82% indicated their intention to continue participating in the program. Aside from its financial benefits, both the publicity and reimbursement procedure of the program were found to be significant factors in influencing the satisfaction of the farmers. Majority of the participants held positive opinions toward the NCMS, contradicting the negative assessments made by many previous studies. Given the high proportion of farmers willing to continue with the program, it is likely to be sustainable in the near future. Greater publicity and education efforts should be made to make the farmers better informed about the program, and measures should be taken to improve its reimbursement procedure and the setting of the premium level.

Experiences with primary healthcare in Fuzhou, urban China, in the context of health sector reform: a mixed methods study

China has recently placed increased emphasis on the provision of primary healthcare services through health sector reform, in response to inequitably distributed health services. With increasing funding for community level facilities, now is an opportune time to assess the quality of primary care delivery and identify areas in need of further improvement. A mixed methodology approach was adopted for this study. Quantitative data were collected using the Primary Care Assessment Tool-Chinese version (C-PCAT), a questionnaire previously adapted for use in China to assess the quality of care at each health facility, based on clients' experiences. In addition, qualitative data were gathered through eight semi-structured interviews exploring perceptions of primary care with health directors and a policy maker to place this issue in the context of health sector reform. The study found that patients attending community health and sub-community health centres are more likely to report better experiences with primary care attributes than patients attending hospital facilities. Generally low scores for community orientation, family centredness and coordination in all types of health facility indicate an urgent need for improvement in these areas. Healthcare directors and policy makers perceived the need for greater coordination between levels of health providers, better financial reimbursement, more formal government contracts and recognition/higher status for staff at the community level and more appropriate undergraduate and postgraduate training.

Regional inequity in financing New Cooperative Medical Scheme in Jiangsu, China

This study examined the regional inequity in the New Cooperative Medical Scheme (NCMS) financing in Jiangsu, China. Counties were classified into three categories according to socio-economic development level: South Jiangsu, Middle Jiangsu and North Jiangsu. Five counties (Changshu, Danyang, Gaoyou, Jiangyan and Ganyu) were selected on the basis of the following criteria: (i) NCMS had been implemented before 2005; (ii) county governments were willing and able to collaborate with the research team; and (iii) counties had different socio-economic development status representing the low, medium and high level of socio-economic development in Jiangsu. As shown in this study, local governments in Jiangsu took the major NCMS financing responsibilities (75.2% in 2009), and local governments (county and lower) subsidies ranged from 220 RMB per capita in South Jiangsu to 18 RMB per capita in North Jiangsu in 2009, with a larger contribution (73.3%) in South than that in Middle (40.0%) and North Jiangsu (18.0%). For achieving more equity in NCMS financing and carrying NCMS forward, we propose that provincial and municipal governments should increase their contribution to NCMS for balancing the regional inequity in subsidies from county and lower-level governments, and the risk pool of NCMS should be promoted to a higher level (e.g., provincial).

Public vs private administration of rural health insurance schemes: a comparative study in Zhejiang of China

Since 2003, China has experimented in some of the country's counties with the private administration of the New Cooperative Medical Scheme (NCMS), a publicly subsidized health insurance scheme for rural populations. Our study compared the effectiveness and efficiency of private vs public administration in four counties in one of China's most affluent provinces in the initial stage of the NCMS's implementation. The study was undertaken in Ningbo city of Zhejiang province. Out of 10 counties in Ningbo, two counties with private administration for the NCMS (Beilun and Ninghai) were compared with two others counties with public administration (Zhenhai and Fenghua), using the following indicators: (1) proportion of enrollees who were compensated for inpatient care; (2) average reimbursement-expense ratio per episode of inpatient care; (3) overall administration cost; (4) enrollee satisfaction. Data from 2004 to 2006 were collected from the local health authorities, hospitals and the contracted insurance companies, supplemented by a randomized household questionnaire survey covering 176 households and 479 household members. In our sample counties, private administration of the NCMS neither reduced transaction costs, nor improved the benefits of enrollees. Enrollees covered by the publicly administered NCMS were more likely to be satisfied with the insurance scheme than those covered by the privately administered NCMS. Experience in the selected counties suggests that private administration of the NCMS did not deliver the hoped-for results. We conclude that caution needs to be exercised in extending private administration of the NCMS.

China's new cooperative medical scheme for rural residents: popularity of broad coverage poses challenges for costs

One of the components in China's massive health reform effort is the New Cooperative Medical Scheme, which is intended to provide affordable health insurance, especially to the rural poor. This program offers three options with different benefits and costs to county health officials, who select one of the options to make available to local residents. Data were obtained from the New Cooperative Medical Scheme survey conducted by the Chinese Ministry of Health and the World Bank in 2005, which covered more than 47,000 people living in twenty-seven counties, to determine participation levels, identify which option was most attractive, and characterize the impact that each option had on care and costs. Our study found that those participants with the most limited coverage might have delayed seeking care, while the broadest coverage--the "Cadillac option"--was the most popular. Yet if this generous package were to be broadly offered, health costs would become unsustainable. Therefore, the Chinese government must consider which costs to cover for people in economically depressed rural areas.

Income-related inequality in health insurance coverage: analysis of China Health and Nutrition Survey of 2006 and 2009

Introduction

China introduced the urban resident basic medical insurance (URBMI) in 2007 to cover children and urban unemployed adults, in addition to the new cooperative medical scheme (NCMS) for rural residents in 2003 and the basic health insurance scheme (BHIS) for urban employees in 1998. This study examined whether the overall income-related inequality in health insurance coverage improved during 2006 and 2009 in China.

Methods

The China Health and Nutrition Survey (CHNS) data of 2006 and 2009 were used to create the concentration curve and the concentration index. GEE logistic regression was used to model the health insurance coverage as dependent variable and household income per capita as independent variable, controlling for individuals' age, gender, marital status, educational attainment, employment status, year 2009 (Y2009), household size, retirement status, and geographic variations. The change in the income-related inequality in 2009 was estimated using the interaction term of income*Y2009.

Results

In 2006, 49.7% (4,712/9,476) respondents had health insurance: 13.4% with BHIS and 28.4% with NCMS. In 2009, 90.8% (8,964/9,863) had health insurance: 10.1% with URBMI, 18.3% with BHIS, and 57.6% with NCMS. The BHIS, URBMI, and NCMS programs had different patterns of population coverage over 10 income deciles. The concentration index was 0.15 in 2006 and 0.04 in 2009. The dominance test showed that the concentration curves were significantly different between 2006 and 2009 (p < 0.05). An income increase per capita by 10,000 RMB was associated with 25.5% more likely to have health insurance coverage (odds ratio = 1.255, 95% confidence interval: [1.130-1.393]). In 2009, there was significant improvement in the income-related inequality (p < 0.001).

Discussions

Comparing 2009 to 2006, the income inequality in health insurance coverage was largely corrected in China through rapid expansion of CHNS in rural areas and initiation of URBMI in urban areas.

Can the New Cooperative Medical Scheme promote rural elders' access to health-care services?

The aim of the present study was to examine the impact of the New Cooperative Medical Scheme (NCMS) on rural elders' access to health-care services. Articles were identified from PubMed, Elsevier, Wiley, EBSCO, EMBASE, SCI Expanded, ProQuest, Google, and CNKI which is the most informative database in Chinese, with the search terms "rural", "China", "old", "older", or "elder", "elderly", or "aged", "aging", "medical insurance", or "community-based medical insurance", or "cooperative medical scheme". Related websites and yearbooks were searched as well. The NCMS has improved the health-care utilization of rural elders, and they have the highest satisfaction with it among all age groups. However, affordability difficulty remained the common barrier for the rural elderly to access quality health care, in spite of the special considerations given to the rural elderly, such as premium remission and free check-ups. Faced with ever-growing health challenges, some impoverished rural elders with poor physical health and functional limitations may lack sufficient access to basic health-care services. Followed by the provider payment reform initiated by the NCMS, a stricter regulation for doctors' prescriptions, clinical practice and disease management is needed to promote rural elders' access to health-care services. Health management for rural elders can be expected for the NCMS to promote rural elders' health-care access once a better coordination between the NCMS and health-care system can be achieved.

Trends of out-of-pocket expenditure for influenza in China Health and Nutrition Survey during 1989-2006

OBJECTIVES

To examine the trends of out-of-pocket expenditure for influenza during 1989-2006 in China.

METHODS

Data were extracted from the China Health and Nutrition Survey (CHNS) during 1989-2006 (in seven waves). A fixed effect model with robust standard errors was employed to examine trends of out-of-pocket expenditure (adjusted to 2006 Chinese RMB).

RESULTS

The out-of-pocket expenditure increased from 11.92 RMB in 1989 to 50.75 RMB in 2006. The final sample for fixed effect model was 23,050 households. Income elasticity of out-of-pocket expenditure was 1.6%. Using 1989 as reference, the predicted increase was 242.23% [95% confidence interval (CI): 225.79-259.50%] in 2006; it was 143.54% in city hospitals [95% CI: 130.43-157.40%] compared to village clinics.

CONCLUSIONS

Adjusted for inflation and income elasticity, Chinese households experienced an increase of more than double the out-of-pocket expenditure during 1989-2006. The expenditure was higher in higher-level facilities. Policy implications include the government fixed-budget financing to health providers could contribute to the rapidly increased financial burden; a referral system should be rebuilt; private health providers may play an important role in containing healthcare price in China.

Evaluation of a pilot cooperative medical scheme in rural China: impact on gender patterns of health care utilization and prescription practices

Background

In 2003 the Chinese government introduced voluntary cooperative medical schemes (CMS), soon to be in place throughout rural China. Families who chose to enroll do so as a single unit and nothing is known about any differential effect of these new schemes on family members. This study evaluates the impact of one pilot CMS in Anhui Province on health care use by girls aged less than 5 years and women 65 years or older, and on the pattern and cost of prescriptions.

Methods

Health care records were extracted covering a 10 year period, before, during and after the pilot CMS in 4 townships, one with the intervention and 3 comparison townships without. The impact of the intervention on the age and gender distribution of patients presenting for health care and on the prescription of certain drugs was assessed by logistic regression. The cost of prescriptions before, during and after the intervention period was also assessed.

Results

203,058 registration and 643,588 prescription records were identified. During the intervention there was a reduced likelihood overall that a patient was female (OR = 0.92: 95%CI 0.87 - 0.97) at the intervention site. Girls aged < 5 years had an increased likelihood of health care (OR = 1.41: 95%CI 1.23 - 1.59) during the CMS, but women ≥ 65 years were relatively disadvantaged (OR = 0.84: 95%CI 0.75 - 0.95). The use of antibiotics and systemic steroids increased disproportionately at the intervention site for patients ≥ 5 years. Prescription costs at the township hospital also increased at the intervention site, particularly for older men.

Conclusions

This evaluation suggests that all family members did not benefit equally from the pilot CMS and that women ≥ 65 years may be disadvantaged by the newly available reimbursements of health care costs through the CMS. It points to the need, in future evaluations, to use individuals rather than families as the unit of analysis, in order to determine whether such health care inequalities are wide-spread and persistent or are reduced in the longer term. The results also support earlier concerns about the influence of new funding resources on prescription practices and the need for regulation of for-profit prescribing.

The Chinese healthcare system: structure, problems and challenges

We describe the structure and present situation of the Chinese healthcare system and discuss its primary problems and challenges. We discuss problems with inefficient burden sharing, adverse provider incentives and huge inequities, and seek explanations in the structural features of the Chinese healthcare system. The current situation will be further challenged in the future by an aging population, an increasing need for privatization and growing expectations about quality of healthcare.

An analysis of farmers' perception of the new cooperative medical system in Liaoning Province, China

Background

Since 2003, the number of pilot areas of the New Rural Cooperative Medical System (NRCMS) has increased in rural China. And the major efforts have been concentrated on the enrollment of prospective members. In this study, we examined the satisfaction of the rural residents with the NRCMS as well as factors affecting their attitudes towards the NRCMS.

Methods

The data for this study were collected from a survey involving twenty counties in Liaoning Province. Interviews and focus groups were conducted between 10^th January and 20^th August 2008. A total of 2,780 people aged 18-72 were randomly selected and interviewed. Data were evaluated by nonparametric tests and ordinal regression models.

Results

71.6% of the study subjects were satisfied with the NRCMS. Single factor analysis showed that attitudes towards the NRCMS were influenced by gender, age, marital status, and self-rated health status. In the ordinal regression analysis, gender, age, and self-rated health status affect satisfaction (P < 0.05).

Conclusions

We found that a considerable proportion of farmers were satisfied with the NRCMS. Gender, age, and self-rated health status had significant effects on farmers' attitudes towards the NRCMS. The Chinese Central Government attempted to adopt active measures in the future to continuously improve the NRCMS, including initiating educational programs, building new medical facilities and increasing financial investment.

China's health system and its reform: a review of recent studies

This paper provides a survey of the recent empirical research on China's 'old' health system (i.e. prior to the spate of reforms beginning in 2003). It argues that this research has enhanced our understanding of the system prior to 2003, in some cases reinforcing conclusions (e.g. the demand-inducement associated with perverse incentives) while in other cases suggesting a slightly less clear storyline (e.g. the link between insurance and out-of-pocket spending). It also concludes that the research to date points to the importance of careful evaluation of the current reforms, and its potential to modify policies as the rollout proceeds. Finally, it argues that the research on the pre-2003 system suggests that while the recently announced further reforms are a step in the right direction, the hoped-for improvements in China's health system will far more likely occur if the reforms become less timid in certain key areas, namely provider payments and intergovernmental fiscal relations.