Evaluation On The Rural Health Care System In Zhejiang Province

ObjectiveTo understand the history and present status of the rural health care system in Zhejiang Province, evaluate the impacts, achievements and focus problems of both New Cooperative Medical System (NCMS) and Rural Medical Assistance System, then make the evidence-based suggestions for provincial health policy-makers to accelerate the realization of expected goals of "Healthy Farmers" Project.Materials and MethodsUnder the direction of evidence-based public health (EBPH) theory, both systemic review of literature and field investigation were employed in the present study by qualitative and quantitative methods.As for literature review, the steps were as follows: firstly, define the topic, secondly, make out the strategy, thirdly, search the newest and best evidence from the studies on the rural health care system in Zhejiang province. Relevant literature sources were from Vip Chinese Science & Technology Database, China Academic Journal Full Text Database, Internet websites publicizing the information about the NCMS, and official documents on rural health from the Zhejiang Provincial Health Bureau.As far as the field investigation was concerned, five counties were selected to represent the province. They were Tongxiang county, Kaihua county, Shaoxing county, Cun'an county and Taishun county.From January 5th to 25th, 2006, county-level health bureaus, the agencies of NCMS, and 1468 sampled farmers from local villages were surveyed by the questionnaires to get the detailed information on the progress of implementing the NCMS and Rural Medical Assistance System. On the other hand, focus interviews were conducted to obtain the views and responses about the implementation of rural health care system from the interest related groups including the administrative health officials, staff from the agency of the NCMS, staff in charge of medical assistance from Bureau of Civil Affairs, directors of township health centers, village doctors and village cadreResultsThe results of the study included the following six aspects:(A) History and present status of rural cooperative medical system in Zhejiang Province1. History of the Old Cooperative Medical System in Zhejiang ProvinceThe old cooperative medical system experienced a tortuous course in Zhejiang Province. It gave to birth and grew in 1960s. And it covered 90% of villages across the province till the mid-1970s. However, since the household contract responsibility system was implemented inl980, rural collective economy had collapsed. As a result, the Cooperative Medical System dependent on it was also partly disorganized. A great part of farmers had to pay out-of-pocket for their health care. In 1988, the Cooperative Medical System only covered 2.4% of the villages. In 1990s, the primary health care program helped to implement the Cooperative Medical System again. However, in 1993, because the fund raised for Cooperative Medical System was regarded by the Ministry of Agriculture as one of the items that increased the farmers' economic burden, the implementation of Cooperative Medical System was struck once again. Accordding to report of the second National Health Service Survey conducted in 1998, only 6.67% farmers in Zhejiang Province participated in the Cooperative Medical System.2. Progress of the NCMS Pilot Program in Zhejiang ProvinceAs one of the first four pilot provinces in China, the government of Zhejiang Province started the NCMS in 27 pilot counties in August, 2003. The preliminary statistics based on the data from those counties in 2004 were as follows: 8590.7 thousand farmers had participated in the NCMS since 2003. The participation rate was 83.13%. The total fund raised was 515.2698 million yuan, the average fund raised per capita was 59.99 yuan. In 2005, the provincial government speeded up the step to spread the pilot program. By the end of 2005, 86 pilot counties implemented the NCMS. There were 24940.1 thousand farmers participated in the NCMS, and the participation rate was 83.97%. The total fund raised was 1504.628 million yuan, and the average fund raised per capita was 60.33 yuan.On February, 2006, when Pingyang County started the NCMS, The NCMS covered all the 87 counties with rural popution in Zhejiang Province, so Zhejiang Province became the first province nationwide to achieve the expected goal ahead of time. So far, 24600 thousand people participated in it, and the participation rate was 71%. There have been 5199.4 thousand person-times benefited from it.(B) Implementation of the NCMS in five pilot countiesAmong five pilot counties, the starting point of the NCMS for Tongxiang County and Kaihua County was July, 2003, for Shaoxing County and Cun'an County was July, 2004, and for Taishun County was December, 2005.From 2004 to 2005, farmers' participation rates for Tongxiang County were 93.09% and 92.57%, for Kaihua County, 81.79% and 81.51%, for Shaoxing County, 87.35% and 95.61%, for Cun'an County, 57.66 % and 80.54 %, respectively. In addition, the farmers' participation rate for Taishun County in 2005 was 62.38%.From 2004 to 2005, the average fund raised per capita for Tongxiang County were 56.92, 49.87 yuan, for Kaihua County, 39.87 and 40.02 yuan, for Shaoxing County, 64.87 and 66.63 yuan, for Cun'an County, 48.98 and 34.62 yuan, respectively. In addition, the average yearly fund raised per capita for Taishun County in 2005 was 39.99 yuan.Among the five pilot counties, the principle of the reimbursement design was "payment in proportion with expenditure and appropriate reimbursement rate", but every county had its own reimbursement scheme according to its local conditions.For example, reimbursement pattern for Tongxiang County was outpatient service with big-sum medical fees, outpatient service for specified diseases plus inpatient service. The reimbursement patterns for both Kaihua County and Taishun County were outpatient service for specified diseases plus inpatient service including women's delivery in hospital. The reimbursement pattern for Shaoxing County was outpatient service for common diseases, outpatient service for specified diseases plus inpatient service. And the reimbursement pattern for Cun'an County was outpatient service with big-sum medical fees plus inpatient service.As far as farmers' benefit from the NCMS was concerned, in 2005, the proportion of the reimbursed person in terms of inpatient service in Tongxiang, Kaihua, Shaoxing and Cun'an County, were 3.15%, 2.53%, 4.10% and 1.99%, respectively. The reimbursement rates in terms of inpatient fees in the four counties were 22.63%, 27.50%, 17.22% and 18.93%, respectively. On the other hand, in the four counties, the proportions of the reimbursed person in terms of outpatient service were 3.98%, 0.22%, 17.43% and 1.44%, the reimbursement rates in terms of outpatient fees were 6.73%, 7.79%, 9.82% and 20.01%.(C) Implementation of the rural medical assistance system in five pilot counties Among the five pilot counties, multiple methods were employed for financing the ruralmedical assistance, and the local government took the main responsibility for financing. In 2005, the fund level per capita financed from the local government in Tongxiang, Kaihua, Sahoxing, Cun'an and Taishun were 5, 3, 4, 3, 3 yuan, respectively.A farmer who still got into trouble with keeping his own living even after obtaining the reimbursement from the NCMS was qualified for rural medical assistance. During the year of 2005, the money assisted per capita in Tongxiang, Kaihua, Sahoxing, Cun'an was 1166.74, 3593.89, 6844.76, 5580.21 yuan respectively. What's more, the fund surplus rate of rural medical assistance in Tongxiang, Kaihua, Sahoxing, Cun'an was 83.75%, 15.99%, 6.35%, 53.23%, respectively.(D) Views and responses of interest related groups on rural health care systemBy conducting focus interview, the views, responses, and expectations on the reform and construction of the rural health care system were obtained from the interest related groups. They were as follows:(1) A great part of the rural policy-holders could not get reimbursement under the present NCMS design, and the co-insurance rate was too high, which meant policy-holders had to pay amajority of the health expenditure out-of-pocket, so the NCMS could not effectively prevent the poverty caused by diseases.(2) It was a difficult task to raise fund from the farmers from door to door.(3) Farmers lacked awareness of health protection and sharing illness risk by mutual help, so their participation in the NCMS was not positive.(4) Farmers kept suspicious of the government's policy because of the impact caused by previous failures of the old cooperative medical system.(5) The standard of medical assistance was still low, poor rural people could not be able to prepay the fee for treating their severe diseases.(E) Farmers' knowledge, attitude and evaluation on the NCMSAmong the causes for participation in the NCMS, 48.85% of the farmers answered that they participated in NCMS for its ability of sharing illness risk, 22.77% for its reimbursement, and 22.54% for responding to the government's call.Whereas, when it came to the causes for nonparticipants, 29.52% of them answered that they were healthy enough not to participate in the NCMS, 25.71% of them thought that the current low reimbursement rate was not worthy of participation.On the other hand, in terms of the extent of satisfaction, 66.13% of the surveyed farmers expressed satisfaction with the NCMS.When asked about the preference for the reimbursement pattern of NCMS, 55.66% of the farmers preferred the reimbursement pattern of outpatient service plus inpatient service, 35.18% preferred reimbursement pattern of outpatient service with big-sum fees plus inpatient service, whereas, 2.08% of the farmers preferred only inpatient reimbursement.(F) Analysis of factors influencing the farmers'willingness to participate in NCMSThe percentage of surveyed farmers who expressed their willingness to participate in NCMS was 88.54%. Then, the logistic regression model was applied in order to explore factors influencing the farmers' willingness to participate. The resultant six significant factors were as follows: personal yearly income level, whether or not a farmer got reimbursement from the NCMS, whether or not a farmer was provided with free health screening, whether or not a farmer heard of other people reimbursed from the NCMS, the extent of farmer's satisfaction with the NCMS and the extent of farmer's knowledge of the NCMS.ConclusionsBased on the above-mentioned results, the present study shows that pilot of rural health care system has been making remarkable progress in Zhejiang Province, which is embodied in the following aspects: ?Both the NCMS and Rural Medical Assistance System have been established, and they have covered all rural areas in Zhejiang Province. ?Feasible mechanism for financing and overall planning of the NCMS fund has been formed. ?Effective methods for collecting the NCMS fund has been explored, different NCMS reimbursement patterns and methods for rural medical assistance have been formulated to adjust to local conditions. @A scientific system for supervision and management has been constituted. ?Informationization of the NCMS has been built up, which not only provides farmers with a lot of convenience, but also promote the work efficiency. ?Farmers' economic burden and risk for health service has been reduced. ?The NCMS has been advancing the reform and development of rural health services.But at the same time, there still exist some issues and challenges. For example, some local authorities haven't recognized that the construction of rural health care system is a long-term, difficult, complex task;the NCMS characterized by overall plan for treating serious diseases has limited effects for preventing farmers from the poverty caused by diseases;the proportion of people benefited from the NCMS is in a low level, so is the reimbursement rate, which, as a result, could not attract the farmers;voluntary participation conflicts with the requirement of high participation rate;farmers are not very satisfied with the current system design of the NCMS;the accessibility and availability of farmers' health service are not good enough;under the current system design of NCMS, preventive services are ignored, or even excluded;the management cost of NCMS is high at present;the rural medical assistance has not been brought into full play, and so on.Therefore, the following six suggestions are made to deal with the above problems: ? Strengthen the external support from the government and legislature to help implement the NCMS. ?Increase the level of average fund raised per capita and the level of health security to prepare for creation of a urban-rural integrated health care system in the future. ?Combine the public health services with the NCMS to achieve a beneficial interaction between them. ?Reinforce the management and supervision of the NCMS. ?Enhance the role of the third party (the NCMS Operating Committee) to inhibit the abnormal rise of the health expenditure. ?Perfect the schemedesign of Rural Medical Assistance to improve the availability of health service for the rural poor. (7)Accelerate the reforming process of rural health to construct a new rural health service system.