| BackgroundEquity is an important indicator to measure the civilization and progress of a society. One of the important goals of a government in the area of social construction is to assure that all its peasants are covered by the New Rural Cooperative Medical System (NCMS) and to insure the peasants of NCMS get a fair and effective medical guarantee. Thus, equity of the insured peasants (i.e. demand sides) is the nature, and the core pursuits of NCMS, and determines the advantages and disadvantages, effectiveness and sustainable development of it. Since began in some pilot areas in 2003, NCMS will cover all the country in 2008.The equity in the coverage, financing, utilization of health services, the cost of compensation and medical aid, etc. of demand sides is not organically integrated in the extensive pilot and comprehensively implemented NCMS more or less, which resulted in weakened effects. In recent years, health policy-makers and researchers have began to focus on the equity of NCMS, but systemic theoretical study of the equity of the insured peasants of NCMS has not been reported so far. As for the microcosmic aspects, the existing empirical researches of the equity of NCMS often only focus on a particular procedure (e.g. utilization or benefits incidence analysis of health services), or a particular aspect of a procedure (e.g. family-financing) and the indexes of equity and their concepts and contents are not unified, etc. Therefore, it is need to undertake a comprehensive and systematic study from different aspects and selecting appropriate indexes. As for macroscopical aspects, the study on the fairness of the evaluation index system (i.e. model) of NCMS or other medical insurance systems has not been reported. Based on the above background, the objectives of the study are proposed.ObjectivesThis study explores the equity of demand sides from both theoretical and empirical aspects in line with both microcosmic and macroscopical levels. (1) As regards the theoretical study, it is to seek the ideological and theoretical basis and the concept, content and to define standards of the equity of insured peasants, and to provide analysis on the existing NCMS from theories such as existing policies and social economics related to the assumptions, principle and the law of equity. (2) In accordance with the empirical study of the equity of insured peasants of NCMS in Jinan City. The basic situation of demand sides in three sample counties is described in different income groups. In addition, the equity in the coverage, financing, utilization of health services, the cost of compensation and medical aid, and other factors are analyzed. In particular, the study pays attention to the insured peasants who have chronic diseases. Furthermore, the factors affecting the equity are explored. (3) The study constructs a quantitative, practical and operable model of equity of insured peasants of NCMS, evaluates the equity of three sample counties and tests the validity, reliability, applicability and feasibility of the model. (4) Some policy recommendations are proposed to improve the equity of the insured peasants.MethodsThe different methods are used in accordance with the objectives and contents of the different studies. (1) Theoretical study. Literature review, comparison and classification, analysis and synthesis, analog summarized and deductive reasoning methods are adopted to summarize and think on the practical experience of NCMS in-depth, to explore the general theoretical basis of NCMS, and to evaluate the equity of the existing NCMS. (2) Empirical study of the equity of insured peasants of NCMS in Jinan City. Three counties in Jinan City were selected as the study sites. The stratified sample method was used to collect the data of sample counties, the operation conditions of NCMS and the basic information of 3240 families (12,011 persons) and their conditions in health services funding, the needs, utilization, cost, compensation and medical aid and so on. The method includes both qualitative and quantitative study, field investigation and literature review. The quantitative method includes the analysis of rate, ratio, relative ratio, t-test, analysis of variance, range, Engel's Coefficient (EC), Health Financing Contribution (HFC), Fairness of Financing Contribution (FFC), Catastrophic Expenditure Household (CEH), use/need ratios, Concentration Index (CI), the Index of Dissimilarity (ID), Logistic regression models, and other descriptive analysis, comparative analysis and multivariate analysis methods. (3) Model study of the equity of insured peasants of NCMS. Improved Delphi method was adopted for the screening of indicators, and their weighting coefficients, and a model of the equity of insured peasants of NCMS was established ultimately; Methods of Factor Analysis, CronbachαFactor Analysis and Cluster Analysis of variance were used to test the structure validity, reliability and the distinction of the model.Main Results and Findings 1. Theory Study. (1)The main thought on equity at present, theory on social insurance, law of diminishing marginal utility, A Theory of Justice by John Rawls, Pareto optimality and Pareto improvement can be used for reference to establish the equity theory of insured peasants. (2)The study summarized the "Five Cardinal Principles" to the equity of insured peasants, including comprehensive coverage to all peasants, paying for NCMS premium according to one's family economic burden, and so on. It states the content and evaluation criteria to a fair number of links and aspects to the equity of insured peasants. (3)The equity of insured peasants has not been improved to the height of it's own subjectively, both in policy and on law level. We should pay attention to a correct understanding, rational knowledge. All the insured peasants have more or less deletion from the fair question of equity.2. Demonstration study on the equity of insured peasants of Jinan City. The insured peasants of different income groups have different levels of difference by gender, age, marital status, educational level and occupational distribution.(1) Equity of Coverage: Participation rates of the poverty population and the floating population are lower than those of the local peasants on an average. Participation rates of the peasants increased as the household income increases. Healthy groups and unhealthy groups, rich groups and poor groups have not been reflected the function of risk pooling fully. Coverage unfairness and adverse selection phenomena need to be improved.(2) Financing fairness:①Adopting uniform payment amount to every insured peasant, financial support of governments at all levels is a regressive subsidy to the essence. Collective economic organizations have not formed a long-term support mechanism to NCMS on the whole.②Adopting uniform payment amount, individual of the insured peasant will inevitably lead to a highly regressive subsidy and burden to the essence to different regions and different family.③The families' HFC of different income groups showed decreasing trend on the insured peasants. The greatest impact factor affecting family HFC was chronic disease, followed by income. Gender, age, marital status, education and vocational factors on the demand side also affected family HFC. Medical burden to families suffering from chronic diseases was significantly higher than that of non-chronic-disease family.(3)Equity of the utilization of health services:①The two-week attendance rate was increased significantly with the increased income increase among the different insured peasants. The two-week non-attendance rate and that for economic reasons were decreased significantly with the income increase among the different insured peasants. Low-income insured peasants utilized more primary health resources. Factors as such EC and chronic diseases mainly affected the attendance probability at the demand sides. Age, marital status, income, and family size of the population impacted the attendance probability of the demand sides. Income factors affected the equity of the out-patient health service utilization.②Utilization ratios of the inpatient health service of low-income insured peasants were higher than those of the others. Non-hospitalization rate which is due to economic reasons were decreased with the income increase among different insured peasants. Different income groups of the insured were different slightly from different levels of medical hospitals. Income factors which have little impact on the equity of the inpatient health service utilization were likely due to tow reasons. In other words, one was smaller flexibility of hospitalization, the other was relating to the larger release of the low-income groups.③With the increase in income, chronic patients in different insured peasants showed a progressive trend.④The ratio of hospitalizing within two-weeks, not hospitalizing within two-weeks, and not hospitalizing for economic reasons of insured peasants with chronic diseases is 3.05 times, 1.64 times and 1.52 times of those of insured peasants without chronic diseases respectively. Patients with chronic diseases are inclined to use village-level and town-level health care resources, while patients without chronic diseases are inclined to use county-level medical resources and above.⑤Insured peasants with chronic diseases are not only the population who make high use of health care resources, but also the population who make low use of health care resources. With high medical expense burden and low health insurance, they are more inclined to become poverty caused by diseases.(4) Equity of compensation for medical expense of insured peasants.①The ratio of NCMS fund distribution between out-patient and in-patient, the embodiment of the policy "mainly to catastrophe" and the benefit incidence of insured peasants are different among the three sample counties.②The calculated results using range method, composing ratio, CI and ID reflect that the demand side out-patient's benefit rate of the high-income group is higher than the low-income groups. The out-patient's benefit rate of the demand-side is unfair, however, the cover benefit of hospitalization inclines to the low-income groups which its fairness is well comparatively.③The calculated results from percentage, range ratio, composing ratio, CI and ID reflect in the lower rate benefit level of out-patient compensation of the demand side, showed that the NCMS funds flowed from low-income families to high-income ones. Not only that, after the NCMS compensates the out-patient medical expenses, the fairness of the out-patient compensation expenses has not only unimproved, but also slightly increased the trend of unfairness.④The calculation results reflected that the NCMS funds incline obviously from low-income families to the high-income families, even though in a condition of lower compensation degree to demand-side hospitalization benefit. After the NCMS compensates the hospitalization medical expenses, the degree of unfairness is improved. Comparing the out-patient fees and the compensation funds of the demand-side to the in-patient fees and compensation funds of the demand-sides, the fairness of the latter is worse than the former, although the unfairness of the latter's hospital medical expenses is improved after compensation.⑤There is a concentration trend of medical expenses and compensation for patients with chronic disease to the high-income group, and the equity was improved after compensation.⑥There was a descending trend of CEH with the increasing of income on the critical points of 30%, 40%, 50%, and the CEH of high-income groups showed a relatively larger declining trend than that of low-income groups. The compensation level of serious disease was very low and the relief effect to catastrophe is still very limited, and the inequity still exists.⑦The CEH of the lowest income group is higher than the other groups. The incidence of CEH reduced with the increase in income. The factors from the age, marital status, the population of the family and chronic diseases influence the incidence of CEH of the demand sides.The characteristic of the study is that many methods are used to measure the fairness of the demand sides in one point and get the consistent results. At the same time, it is found out or showed that advantages and disadvantages are all coexistence when some research methods are used for the fairness on the different links of the demand sides.(5) Medical salvations which were carried out in three sample counties are more significantly behind NCMS. Moreover, there are also some questions, e.g. uneven progress, unstandard management, low coverage to the poor, and the extremely low level of funding difficulties and so on, that could not provide basic medical security for the impoverished population, and bear the weight of "carrying the bottom line of the fairness".3. The establishment and application of evaluation indexes system for demand-side of NCMS. (1)Because of the logic selection for the indexes, the rationality for the weighting coefficients, the established evaluation indexes system for fairness at the demand-side of NCMS is applicable and exercisable. (2) This study makes the explanation for the indexes of the demand-side's fairness, valuation methods and standards score table of NCMS in Jinan City, and then makes use demand-side model of fairness to get three sample counties' weighted cumulative combined scores of the equity of the demand sides. It is the degree of the fairness which is carried out in three sample counties has good reliability, validity and distinction by the analysis, that proves the model of the fairness of the demand-sides can be carried out in practice and has universal significance and extended application value. However, it is necessary to be further validated in practice, and constantly improved along with the cognition which is becoming maturated.Policy Recommendations:(1) Governments should pay more attention to the equity of demand sides, and prioritize the "emphasizing demand side equity, improving medical security utility" into principles of NCMS explicitly. The NCMS should realize the transition to the direction progressively from the "low level, wide coverage" to the "appropriate level, comprehensive coverage, paying premium according to economic level, meeting basic medical demands, equal benefit and differential treatment of demand sides". (2) Applying established aim of demand side equity, the policy to improve the demand side equity should be implemented gradually depending on stages, contents, levels and population groups. (3) Legislation is generally implemented, and NCMS should be translated into compulsory insurance, only by which can NCMS accomplish general coverage and equity in social inclusion. (4) Reforming and improving financing methods should be based on "four stages" strategy, which is from rough to exquisite, from quota to ratio, from area to family, reducing unit of financing and improving equity in financing gradually. (5) Emphasizing corresponding infrastructural construction of rural primary health care facilities, and improving utilization level of these facilities. (6) According to anti-Matthew principle, demand side subsidy design should be improved to minimize the benefit gap, as well as wide benefit population and benefit level generally. (7) Facilitating construction of medical aid scheme, which is supplemental to and combined with NCMS to form the unified administrative system and operation mechanism. (8) For chronic patient, the classification reimbursement scheme should enlarge the reimbursement scope and level.
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