| BackgroundNew rural cooperative medical scheme (NCMS) is a form of social health insurance scheme, which, since its inception in 2003, is subsidized voluntary health insurance program. The scheme's focuses on the "inpatient-fee pool", and also pay attention to the outpatient expenditure. Since the pilot in 2003, the scheme has been developed rapidly while the coverage and the fund have both got new high level. At the end of 2009, the scheme has covered more than 94%of rural residents, and more than 1.5 billion person times got reimbursements from scheme, and the total reimbursement was more than 120 billion RMB yuan. However, the barrier of NCMS'long-term development is becoming clearer:with the rapid development of coverage and fund, how to improve the NCMS'capacity of protecting?At present, the prevalence of non-communicable diseases (NCDs) in rural China is becoming serious, while the disease economic burden becoming heavier and heavier. The NCDs have become the major cause of rural residents' health and economic risk. In accordance with the NCDs prevention theory, the NCDs' prevention should follow the "three early" principle, which is early find, early diagnose and early treat. The "three early" principle helps to reduce the incidence of NCDs and finally reduce the economic risk of rural residents with NCDs. However, because we did not recognized the importance of NCDs control during the social-economic change, the incidence of NCDs is getting higher rapidly while the economic burden is getting heavier. Under the circumstance, the first job is to establish the health insurance in order to reimburse the rural residents with NCDs. So that their health care availability will be improved and they will get their health insured.Now, the NCMS the only health insurance which aims to cover all the rural residents protects rural residents. Only to clear the denotation of NCMS'capacity of protection and the current situation of NCMS protecting rural residents with NCDs, can we improve the NCMS in order to strengthen its protection capacity.ObjectivesThe objective of the study is to analyze the NCMS's capacity of protecting rural residents with NCDs. and to suggest the recommendations for improving the NCMS in the future on the basis of studying the denotation of NCMS'protecting capacity and the evaluation. The following special objectives are included:studying the denotation and the evaluation system of NCMS" capacity of protecting rural residents with NCDs, analysis of the current situation of NCMS' ability in protecting rural residents with NCDs and making the shortcomings and the advantages clear, supposing recommendations to improve the NCMS'capacity of protecting rural residents with NCDs.ResourcesThe resources of the study include the literatures and investigation. The literatures come from the library of Shandong University, including e-books, e-magazines, books and macroscopically health statistics data basis. The investigation datum roots in baseline investigation and final investigation of Luxemburg-WHO-Shandong rural health workers training and chronic non-communicable diseases control program, including household investigation, institution investigation and informational interview.MethodologyThe study analyzes the pathway of NCMS protecting rural residents with NCDs based on the literature review, then studies the denotation of NCMS' capacity of protecting rural residents with NCDs.Taking denotation of NCMS'protect ability as the basis, the study constructs the system for evaluating NCMS' protect ability for rural residents with NCDs combining literature review on NCMS protect ability. The evaluation system for NCMS' core protect ability includes breadth, depth and height; the connotative protect ability includes guarantee health of rural residents with NCDs, regulating the health providers'and demanders'behavior, promoting the health care for NCDs to be socialized.The study methods include systematic analysis, literature review, expert consultation and so on. Univariate analysis and description analysis with SPSS software are used to address the data.Results and findingsI The denotation and evaluation system of NCMS's ability to protect rural residents with NCDsThe nature and functions determine the denotation of NCMS's ability of protecting rural residents with NCDs. At the beginning of pilot, the NCMS was defined as a commune to help system between rural residents. After that, lots of researchers argued that the NCMS has got the nature of health insurance. In October,2010, the Insurance Law of Peoples Republic of China take NCMS as an health insurance, which meaned that NCMS have become part of health insurance system and got the nature of health insurance. In accordance with the theory of health insurance and social health insurance, NCMS should perform social welfare, mandatory, economy and public welfare as one of social health insurance of our country. Besides the core ability, reducing economic risk of rural residents with NCDs, NCMS should also have the function of guaranteeing the health of rural residents with NCDs, regulating health providers'and demanders" behavior, and making health care for controlling NCDs be socialized, which includes health examination and establishment of health files.Theoretically, NCMS protects rural residents with NCDs by three pathways:directly reimburse health expenditures occurring in health organizations and drug stores, guide the rural residents with NCDs reasonably chose health organizations, provide public health care, including health examination and establishing health files, to rural residents with NCDs.On basis of nature and functions of NCMS, the paper argues that NCMS'ability of protecting rural residents includes two parts:core ability, which means reducing economic risk, and connotative ability, which means guaranteeing health, guiding health behavior and public health care.2 Prevalence of NCDs in rural areasThe prevalence of hypertension and diabetes in rural areas was 10.50%and 1.05%, prevalence of female is higher than male, high incomes higher than low incomes when baseline investigation. The other NCDs includes cardiovascular and COPD and so on. The final investigation shows that the prevalence of hypertension and diabetes is 17.19%and 3.04%, which is relatively lower than that of baseline.3 The NCMS policy on reimbursement to rural residents with NCDsIn 2007, there were four counties, Laicheng, Guangrao, Ningyang and Cangshan, which made NCMS policies on reimbursement to rural residents with NCDs, while the number become eight in 2010. In accordance with the policies, the reimbursement ratio of outpatient in township health center is between 30%and 60%, which is between 30%and 50%in county hospitals. The reimbursement ratio of inpatient is between 40%and 70%in township health centers, which is between 15%and 70%in county hospitals.4 Analysis of NCMS ability of protecting rural residents with NCDs1) Analysis of NCMS'core ability of protecting rural residents with NCDs. NCMS has covered more than 90%of the rural residents with NCDs in 2007. And the coverage of hypertension and diabetes is 93.61%,92.04%and 92.71%,86.52%respectively in 2007 and 2010. NCMS covers more high income rural residents with NCDs. On basis of China poverty line, NCMS reduce poverty rates of hypertension and diabetes by 1.32%,5.17% and 9.12%,4.00%respectively in 2007 and 2010, which is higher in high income patients, so is between sample counties. In accordance with World Bank poverty line, NCMS reduce poverty rates of hypertension and diabetes by 1.54%,2.70%and 8.71%,3.45%in 2007 and 2010 respectively, which is higher in high income patients, so is between counties. The benefit rate was 29.84%in 2007. which of hypertension and diabetes is 28.64%,27.84%and 45.56%,29.08%in 2007 and 2010 respectively, which is different between counties.The ratio of reimbursement for rural residents with NCDs was 4.71%, while the ratio of reimbursement for one outpatient and inpatient was 4.65%and 8.39%respectively in 2007. The ratio of reimbursement for diabetes' outpatient and inpatient was 5.71%and 7.91% respectively, while the other NCDs was 4.23%in 2007. The reimbursement ratio for hypertension and diabetes annual health expenditure is 4.34%,4.95%and 26.98%,24.10% respectively in 2007 and 2010, which is a little higher in high income patients. NCMS reduces the catastrophic health expenditure gap of hypertension outpatient and inpatient was 6.54%and 13.13%respectively in 2007, which of diabetes was 2.87%and 26.99% respectively. The catastrophic health expenditure gap of hypertension and diabetes reduced 11.64%,4.66%and 26.69%,48.10%respectively by NCMS in 2007 and 2010. In accordance with China poverty line, NCMS reduce positive poverty gap of hypertension outpatient expenditure and inpatient expenditure was 31.35%and 1.57%respectively in 2007, which of diabetes was 8.04%and 6.16%respectively. NCMS reduces the positive poverty gap of hypertension and diabetes by 26.28%,15.98%and 20.34%,13.13%respectively in 2007 and 2010, which is higher in high income rural residents with diabetes. On basis of World Bank poverty line, the positive poverty gap of hypertension outpatient and inpatient expenditure was reduced by 0 and 22.54%respectively in 2007, which was 2.28%and 6.42%respectively. NCMS reduces the positive poverty gap of hypertension and diabetes annual health expenditure by 1.93%,21.57%and 9.09%,58.33%respectively in 2007 and 2010. The equity of protect ability shows that the index of financing equity for hypertension patients, diabetes patients and other NCDs patients was 0.9831,0.9968 and 0.9954 respectively in 2007, which of hypertension and diabetes is 0.8162 and 0.8123 respectively in 2010. The Lorenz curve is below the absolute equity curve, which means that the reimbursement of NCMS concentrates in high income crowd.2) Analysis of the NCMS's capacity of protecting rural residents with NCDs under different reimbursement ratio. The paper analyses the NCMS's capacity of protecting rural residents with NCDs with the outpatient reimbursement ratio is 20%,30%,40%and 50%respectively, and the inpatient reimbursement ratio is 40%,50%,60%and 70%. When the ourpatient reimbursement rarion increased to 50%from 20%, the percentage change of poverty ratio increased to 28.21%from 7.32%, which of catastrophic health expenditure poverty increases to 41.91%from 15.73%, and that of positive poverty gap increases to 35.01%from 8.41%.3) Analysis of NCMS'connotative capacity of protecting rural residents with NCDs Percentage of hypertension patients and diabetes patients visit doctor in four weeks prior the investigation increases by 8.63%and 7.63%respectively, while the percentage of inpatient attendance increase by 54.07%and 2.01%respectively. Percentage of rural residents with hypertension and those with diabetes chose village clinic center increase by 11.74%and 317.04%respectively. And the difference is significant among income group. The low income patients are affected more by the policy change. And the percentage of hypertension patients who have inpatient services in township health center increase by 108.16% significantly. The percentage of rural residents with hypertension and those with diabetes who buy medicine from village clinic center increase by 15.46%and 79.44%respectively, while low income patients prefer village clinic center better than the high income patients. To regulate health providers" behavior, the management office of sample counties all made measurements, such as clearing the responsibility of health organization, prescription of doctor and so on, in order to control the health expenditure. Especially, the management office of NCMS in Shouguang constructs regulations on chronic outpatients funds pool of new rural cooperative medical scheme>, which make the special responsibility of health provider clear. At the same time, NCMS in sample counties also provide health examination to rural residents who participate into NCMS, and establish health files for them. These measurements not only let more rural residents like to participate in NCMS, but also make the "early find" and "early intervention" to NCDs come true on basis of NCDs patient management. Finally, these measurements which will help strengthen NCMS's ability to protect rural residents with NCDs will help control the disease development and reduce the economic risk.Conclusions and recommendationsThe study argues that the breadth index of NCMS protect rural residents with NCDs is higher than average of total group, however the depth index is far below the average of total group of NCMS while the height index is similar. Therefore, the big potential protect ability need to be developed. Overall, NCMS's ability to protect rural residents with NCDs is weak.In order to improve NCMS's ability to protect rural residents with NCDs. following recommendations are provided:increasing reimbursement rate in root health care services in order to improve the efficient of protecting rural residents with NCDs, giving rural residents with NCDs more reimbursement in order to help them against "poverty because of diseases" making special reimbursement policy for rural residents with NCDs, increasing reimbursement rate of outpatient, putting NCDs into heavy disease burden pool, giving reimbursement to medicine fee in drug stores, changing equity of reimbursement, combining NCMS with public health works to help improve NCDs prevention.
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