| 1. Objective and SignificanceThis study is a component of the project "Research of Definition and Tactics on Key Issues in Chinese Primary Health Fields", which is granted by the State Ministry of Education Doctor Spot Fund (20020246078) and the State Distinguished Youth Fund (79925002).As the foundation of social development, health service is one of important functions of government. But there are lots of questions to be solved in health services and different questions exist in varied felids. The complexity of questions makes it hard to grasp the blankness of research for policy-researchers and the threshold of solving problems for policy-makers. There are no corporate directions and objectives for both policy-researchers and policy-makers. On the whole, it is not easy to decide the order of questions which one should to be solved at first in rational and scientific way since every field emphasizes importance of itself. So the efficiency of solving related issues will not be improved unless the questions mentioned above disappear.Considering on the strategic level of health development, the project "Research of Definition and Tactics on Key Issues in Chinese Primary Health Fields", based on domestic issues, is to observe, analyze and definite the existed and potential social issues in primary health fields during special periods; and to definite issues' degree of importance and severity, the priority order to be solved, to grasp the key issues which have priority to be regarded; at the same time, aiming at the most important issues, study which factors effect on them, form into policy suggestions and project, including key techniques, practical steps, obstacles, conditions, and so on.Analyzing the situation of our country, rural area is the root of economic development, social stability and independence of state. Compared with the progress of macro economy and urban health reform, rural health is more important and complex, which have more questions and lag behind social development. Rural health services and medical corporate system become the underlying factors which influence on the stability of rural society.This study belongs to the general project "Research of Definition and Tactics on Key Issues in Chinese Primary Health Fields", aiming to definite all issues and priority issues need to be solved in rural medical social security, grasp the blankness of research from the eyes of policy-researchers, study the limitation and think it over as an entry of solving problems from the eyes of policy-makers, establish the cooperate objectives for both, make up the blankness and limitation of the special issue and demonstrate by practicedata, accumulating experience for further research.This study includes three parts: "issues definition", "research status" and "technology of data demonstration". The first part starting with definition of rural medical social security, gather existed problems and classify into various issues, prioritize the order of solving. The second part lay stress on finding blankness of research and limitation of decider-making for a few special issues. The last part emphasizes several technologies to solve the focus issue by data demonstration to make up blankness and limitation accordingly.2. Research MethodologiesThe design of this study is to embody "three preconditions", "four combinations" and "six basements". It means that the study premises with "defining issues and their orders to be solved", "ensuring blankness and limitation of focus issues" and "making up blankness and limitation of special issue"; takes "combining scientific research with the situation of our country, quantity with quality, research with decision-making, multiple subjects intercrossing" as principles, embodies "system, science, advance, logicality, rationality and maneuverability ".UA Scientific Policy-Making Procedure" established by research team was selected as the supervising research method for this project. "A Macro-Model of Health System" was used to provide the systematic thinking of this research. "The Multi-dimension combined Evaluation Method" was chose to supervise the outline of research contents. At the same times, most of main viewpoints gained from the process of research were demonstrated qualitatively and quantitatively.In the part of defining issues, the study designs evaluating indexes of literatures and makes an analysis of reliability and validity, classifies problems by "A Macro-Model of Health System", ranks issues by their importance with APH and the index of severity, sorts issues into four class by their importance and severity, weights importance and severity with the method of CV, gain the integrate order consulting the resolvable quality of issues. 626 pieces of literatures come from CNKI and VIP database of 2003,2004 two years.In the part of research status, with "A Scientific Policy-Making Procedure" as criterion, we evaluate 227 pieces of literatures with indexes mentioned above. Comparing ideal situation with realistic status of literatures, we ensure the blankness and limitation.In the part of demonstration simulation, the study inherits previous production of our research center, builds the system of evaluating indexes, the frame and measures of key indexes for new cooperate medical system(NCMS) with methods of "A Macro-Model of Health System", field analysis, economic risk for medical service, Coefficient of Gini, Lorenze Curve, and so on. Data comes from field investigations of Jiading District, Shanghai and a county as an experiment unit of NCMS in Huadong region. Data-collecting method includes routine data collection, sample survey, and intention survey.3. Research resultsPart One: Definition of Key Issuesâ‘ Definition of Chinese rural medical social security fieldDualistic economic system leads to duality of Chinese medical social security. According to influence of policy-makers and interest of policy-researchers, the special field of this study is system and mechanism which arranges public health services and related heath social resources.Cooperative medical service (CMS), which comes through budding period in 1940s, period of setting up in 1950s, period of development and splendor in 1960s and 1970s, period of disaggregating in 1980s and resuming period in 1990s, constitutes system of rural medical social security during planning economics times. Now CMS begins the new developing period with State Department deciding to build NCMS for rural residents. In future 10 years, NCMS will be face with challenge of durative financing, fitting reimbursement, scientific management, effective monitor, medical security of land-lost fanners, medical rescue of poverty population and medical social security plan as a whole for residents in urban and rural areas. â‘¡Definition of existed issues in Chinese rural medical cooperative service626 pieces of papers refer to 237 kinds of periodicals. Most of them are of argumentum (40.4%) and quality (51.7%). 40.9% of authors come from university and research institution. Reliability and validity of evaluating questionnaire for literatures is satisfied (Kappa>0.75).We collect 50 kinds of problems from literatures, and then classify them into 32 kinds of issues by "submodel-conception-index" in "A Macro-Model of Health System". We make a precise definition of manifest, harm, acting range and logic relationship within issues. â‘¢Affirm the priority of issuesUsing APH we make an order of issues by importance: the duality of medical security, the mechanism of financing is not sustaining, CMS lacks of law security...32 issues can be ranked by index of severity: "Poverty Caused by Diseases", CMS "setting up in spring and collapsing in autumn", social groups are impercipient...In theory, importance is priority to severity; we classify issues into four categories. Then we rank issues by index of solving priority within every category, the integrative order is: the mechanism of financing is not sustaining, the mechanism of reimbursement is not rational, the duality of medical security...Integrating with resolvable likelihood of issues, we affirm important and serious key issues, the first 10th is: the mechanism of financing is not sustaining, the mechanism of reimbursement is not rational, CMS lacks of law security,..., social groups are impercipient, "Poverty Caused by Diseases". Part two: Research StatusBecause of restrictions such as time, this part select four issues, two of them from key issues, the othertwo from socially concerned issues. They are "Poverty Caused by Diseases", CMS "setting up in spring and collapsing in autumn", the mechanism of financing is not sustaining, the mechanism of reimbursement is not rational. We call the four issues as socially concerned issues generally in this study.Research of the root and function mechanism on these socially concerned issues is rather mature than other primary heath fields. But most of them are of experience and institution, lacking of systematic discussion with quantitative and qualitative methods. The conclusions are not consisted with each other. So we need to do a systematic demonstration of "acceptant degree of groups", improve rationality, logicality, maneuverability, scientific character of research.Research of policy strategy is also of experience and institution, most of them are discussing suggestions. On the one hand, most are not based on the analysis of root function. On the other hand, even policy strategy is based on root analysis, the acceptant degree need to be demonstrated by investigation. Further research should study systematically about restriction, condition, impetus, resistance, key technique, responsibility of social groups.Although 79 pieces of literatures refer to practical plans and steps, but these practical schemes are based on deficiency research mentioned above. And the current research lack of systematic evaluation, evaluating methods, and key indexes for implement of policy schemes. Part three: Solving Technology and Demonstration Simulation"Poverty Caused by Diseases" is the most worried one of many problems which influenced the stability of rural society. From results of our research before, there are two determining roots on "poverty caused by diseases". One is the collapsing of rural medical social security system in past 20 years, the other is that medical fee increased much fast than income of rural residents. There are two underlying approaches to avoid "poverty caused by diseases", one is to build and perfect system of rural medical social security, the other is to control increasing of medical fee. To solve "Poverty Caused by Diseases", it needs study on technology of evaluation.Technology one: definition and measure method of "Poverty Caused by Diseases"Use this set of methods and indexes synthetically, all right ration: (1) Appraise the degree of reaching of the policy goal. It is one of the main goals of the new-type cooperative medical system policy to alleviate "Poverty Caused by Diseases", what if its policy goal reach the degree? Whether we can get many quantization of angle appraise the result in data the following. The new-type cooperative medical system of one county in East China causes the coverage rate (scope) of system 0.9% drops to 0.2%, has reduced by 0. 7 percentage points, the function of the cooperative medical system is 77.7%; Cause the gap rate (depth) of "Poverty Caused by Diseases" by 1 .3% drops to 0. 3%, having reduced by a percentage point, the function of the cooperative medical service is 76. 9%; Cause the intensity index (namely causes the poor one due to illness sharply) by 5. 0% drops to 1.7%, has reduced by 3. 3 percentage points, the function of thecooperative medical system is 66. 0%; we can find out, the new-type cooperative medical system has been alleviated "Poverty Caused by Diseases" to a great extent. (2) Compare ability to alleviate "Poverty Caused by Diseases" with the different cooperative medical system scheme. According to result of the data, the new-type CMS ability in alleviating scope and intensity of poor, implementation of one county in East China is superior to Jiading of Shanghai, but the function ability in alleviating and causing the poor depth due to illness in Jiading of Shanghai is stronger, prove the new-type CMS scheme of " taking comprehensive arrangement for serious disease as the core " is reducing and causing the poor coverage rate due to illness and causes the poor sharp degree due to illness (lighten the advanced hospitalization cost) the ability of the respect is stronger, and it is better than the high ability in alleviating causing the poor degree due to illness of the whole crowd of CMS of Jiading to ensure competence. (3) Offer basis on which make and adjust the scheme. Cause all budgets that the poor shortfall tells us to solve the poor problem due to illness, offer the adjusted thinking of two kinds of schemes to us: Base on the premise that existing scheme does not change, per capita to need what does it raise funds of more, to solve poor problem due to illness in theory just, if East China some county per capita to raise funds of 14 Yuan, the poor problem due to illness can be solved and according to existing scheme; Under raising funds does not change as the prerequisite, adjust the concern degree to the serious disease of scheme, on the issue that can solve and poor due to illness in theory, such as adjust the concern degree to the serious disease of scheme of Jiading of Shanghai to 91.3% can solve and the poor problem due to illness.Technology two: Measurement method of the economic risk for medical service Through developing the corresponding measure technology and method, can ration: (1) Evaluate effect of CMS on reducing economic risk for medical service. RR value drops by 14.4% wholly after the CMS of Jiading of Shanghai is compensated, especially 3000-5000 expenses section. (2) Appraise CMS function to reduce economic risk of clinic crowd and crowd seek medical service in hospital. After compensated by CMS of Jiading of Shanghai, RR value of the clinic crowd reduces by 12.4% wholly, concentrate on expenses section under 2000 Yuan mainly; The RR value of crowd in hospital reduces by 19. 3% wholly, it finds to be 2001-3000 and 8000-10000 expenses piece. (3) Appraise CMS function to reduce economic risk for medical service with crowd seeking medical service in different levels medical organization. RR value of crowd in three tiers of level of clinic drop to some extent after being compensated by CMS in Jiading Shanghai, among proportion of dropping township hospital is the largest, it is 26. 3%; To crowd in three level hospital, RR value of township hospital drop heaviest among them, it is 25. 9%. (4) Evaluate function of CMS to reduce economic risk for poor crowd. After compensated by CMS in Jiading of Shanghai, by the look of clinic, corrected RR value the poor crowd has dropped 34.5%; respecting on hospital, correct RR value of poor crowd drops 43. 1%. (5) Evaluate function of CMS to reduce economic risk of high-risk group for medical service. After compensated by CMS in Jiading of Shanghai, the whole RR value of thehigh-risk group declines 14.7%.Technology three: Method to appraise the basic manage status in CMSThrough appraising the basic manage status in CMS, find: there are phenomena that funds of farmers arrears in some towns (2/7 ) in Jiading of Shanghai; Competence of financing is widely different among towns; Status of funds management in some towns are not good enough, three are 3 towns which surplus greater than 35% and 1 town loss has appeared of all 7 towns. Use basic structure - process - outcome index system for appraising; it is easy to find defect of t management, and correct in time.Technology four: Appraisal method of constant financing mechanism in CMSAccording to the systematic appraisal method, this research put forward frame and index system for appraising constant financing mechanism in CMS. It considers environment of financing policy, financing management (plan, organization, channel, way, control) as a whole, explain the inner link of every key element and essential feature within finance in new-type rural CMS. And according to some indexes in this frame, it applies to appraise constant of the individual finance of CMS in Jiading of Shanghai.The rate of joining CMS of peasant household in Jiading of Shanghai is 91.5%. 79. 1% peasant households have enjoyed the compensation of CMS; The renewal of insurance rate of will is up to 92.6%; Supreme compensation volume reaches 30000 Yuan; Rural resident is willing to provide 235 funds, actually funds of 149, funds providing in will than actually isvl:l. 58; Per capita to join the premium / per capita family income is 1. 9%; There is balance in CMS of most villages and towns; we can think tentatively the continuation of financing and management is very high in Jiading.Technology five: Force field analytical methods of relevant interest group of CMS"Force Field Analytic Approach" can detailed make contrast of strength of influence factor comparatively, offer the scientific thinking basis to policymaker. Have introduced and adopted the formula of transformation based on natural index to "approval rate of factor's importance ", it makes the balance of force in capable analysis charts much clearly. At the same time, because it adjusts based on size of obstruction oneself, which have guaranteed the size of the intensity of graphic presentation still can be compared among the obstruction in the investigation result among the different area, different time, different crowds.Appraising function of new-type CMS scheme to dispel potential reasons which cause traditional CMS "setting up in spring yellow in autumn". Every obstruction has improved in various degree after the new-type CMS is implemented; Among them the obstruction that government's attention degree and policy authoritativeness are not enough changes biggest, have weakened 62. 2%; Secondly lack the unified goal for government's part, this obstruction has weakened 50%.Technology six: Measurement on ability of CMS to improve the rural resident's income equityMaking use of the principle of GJM coefficient and Lorenze curve, (1) Measure the influence offinancial burden of disease on rural resident's income distributing equity. GINI coefficient increases 25.6%, after paying hospital expenses in Shanghai Jiading, and GINI coefficient rises by 20. 2%, after paying hospital expenses in a county of East China. (2) Appraise the ability of CMS to improve the equity of incomes. The new-type CMS acts on the rural resident's income equity to some extent, the new-type CMS in one county of East China which "taking comprehensive arrangement for serious disease as the core", improve hospital crowd's income equity 49.1%. (3) Compare the ability of improving crowd's income equity with different CMS schemes, offer the thinking for adjusting the scheme. Because schemes are different to the concern degree of the serious disease, its ability to improve crowd's income equity is different, Jiading of Shanghai is stronger when comparing the ability in improving clinic crowd's income equity than one county in East China, and East China some county is better than the former to improve equity of hospital crowd. Compare improving degree of more different risks crowd's income equity, East China some county equity more to influence positively at the county level, comparatively speaking, Shanghai Jiading should strengthen the clinic expenses of large volume and concern degree of the expenses crowd in hospital to improve ability of CMS. (4)Appraise level and mode of finance. GINI coefficient only rises by 0. 4%, after paying CMS funds in a county of East China, competence is within the rural resident's economic ability to bear that it finances. 4. Innovations(1). Definite rural medical social security field, grasp numerous problems exactly, form a list and structural model of issues.(2). Rank issues by priority to solve with scientific methods, hold key issues and socially concerned issues.(3). Verify and perfect "A Scientific Policy-Making Procedure" which combine "scientific research with the situation of our country, quantity with quality, research with decision-making, multiple subjects intercrossing" on contents and methods, especially the process of policy issue identification.(4). Grasp the blankness of research from the eyes of policy-researchers, hold the limitation and make an entry of solving problems from the eyes of policy-makers.(5). Establish cooperating objectives and harmonious mechanism for both policy-researchers and policy-makers, also can form a series of innovations for further research(6). Demonstrate special socially concerned issue with actual data, offer evaluating technologies of NCMS to make up blankness and limitation, build innovative key indexes.(7) Innovate and verify 3 integrate indexes to measure "poverty caused by diseases": indexes of scope, depth and intensity. Combining with the concern degree to the serious disease, we can define per capita to solve poor problem and to existing financing level how great degree is scheme solve poor due to illness,...
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