| In 2009,the Central Committee of the Communist Party and State Council of China issued Opinions on Deepening the Health System Reform.As a programmatic document guiding the health system reform,it proposed that “a multiple health inputs mechanism led by government should be established”,which indicates that the financial power of government in healthcare should be transformed and strengthened.In 2016,the State Council issued Guiding Opinions on Promoting the Reform of the Division of Financial Powers and Expenditure Responsibilities Between the Central Government and Local Authorities,further proposing to achieve the division of financial powers and expenditure responsibilities between the central government and local authorities,gradually realizing sharing of financial powers and clarification of responsibilities between the central government and local authorities in basic public services such as basic medical insurance for urban and rural residents,basic medical care and public health,so as to improve the efficiency of public services provision,thereby encouraging governments of all levels to better perform their duties.The Report of the 19 th National Congress of the Communist Party of China in 2017 also stated that “We will deepen reforms of the medicine and healthcare system,and establish distinctive Chinese systems for providing basic healthcare,medical insurance,and quality and efficient healthcare services.” In recent years,with the establishment and improvement of basic medical insurance system being a hot issue concerning every reform in the field of healthcare,wide range of tax sources provide strong financial support for government to run the basic medical insurance system.However,China is still facing increasing challenges caused by soaring medical spending.The financial expenditure of healthcare,especially of basic medical insurance,is increasing rapidly.The construction of basic medical insurance system gives government greater financial responsibilities but also brings greater expenditure pressures as well as a series of questions concerning financial expenditure.Questions coming up include how to define the responsibility and scale of financial expenditures of basic medical insurance,how to divide financial powers and expenditure responsibilities between the central government and local authorities,and how to construct a framework to evaluate financial expenditure performance of basic medical insurance.Before solving these questions,concepts pertaining to basic medical insurance and financial expenditure should be defined.The concept of basic medical insurance comes first.Basic medical insurance is under the regulation of national legislation and provides effective protection for people’s acquisition of basic medical and health services by proportionally compensating part of the outpatient and emergency,hospitalization expenses of the insured.Most of the cases,it is broadly referred as medical insurance in China.At present,the basic medical insurance system embraces three schemes,the Urban Employee Basic Medical Insurance Scheme for workers in urban areas,the Urban Resident Basic Medical Insurance Scheme for urban residents and the New Rural Cooperative Medical Scheme for rural residents.Different schemes cover different groups and provide different types of compensation.The second is about the definition of financial expenditure of basic medical insurance.The fund of basic medical insurance is raised mainly by governments,employers and individuals,among which government financing plays a vital role.It not only guarantees the running of the basic medical insurance system,but also redistributes resources.Government redistributes basic healthcare resources which are originally distributed under the influence of market,thus promoting balanced development of public health.The third definition comes to financial expenditure performance of basic medical insurance.The financial expenditure performance management of public service programs plays an important role in implementing the scientific development,promoting government transformation,improving financial management,and alleviating the contradiction between income and expenditure.Hence,the financial expenditure performance management of the basic medical insurance plays a key role in the supply of quality medical services,the improvement of health care inputs and outputs,and the improvement of health equity.According to theories and existing research at home and abroad,the right to health theory believes that everyone enjoys the right to health and shall not be deprived of this right due to inability to pay or social,cultural or geographical differences.Based on the right to health theory,the basic medical insurance system is the key to protecting individual’s health and improving the overall welfare of the society.Public finance is an important guarantee for achieving universal coverage of basic medical insurance.Many studies at home and abroad pay attention to government’s responsibility in financial expenditure and emphasize the need to divide financial powers and expenditure responsibilities between the central government and local authorities.As for proportion of specific expenditure,there is not an agreed-upon answer.Some scholars believe that government should take almost liabilities of basic medical insurance(unlimited expenditure responsibilities),but others think otherwise and believe that government should shoulder partial liabilities of basic medical insurance(limited expenditure responsibilities),because unlimited government expenditure responsibilities are often financially unsustainable.Besides,considering the revolution of basic medical insurance,government’s financial expenditure responsibilities of basic medical insurance have been dynamic and were endowed with different connotations in different periods.In the process of constructing the basic medical insurance system,the structure and scale of financial expenditure of basic medical insurance has also been constantly changing.In the initial stage of medical security system construction,from the founding of new China to reform and opening-up(1949-1978),government took a wide range of responsibilities,ranging from legislation,administration to financial expenditure management.And medical insurance system at that time mainly included Publicly-financed Health Insurance Scheme for Urban Residents,Labor Insurance and Rural Cooperative Medical Scheme.However,with the increasing financial burden and the transformation of the economic system(from planned economy to market economy),social medical security system in the 1980 s experienced market-oriented reform,and part of government’s financial power gradually shrank.In 2007,the 17 th National Congress of the Communist Party of China pushed the construction of medical security system forward to a new historical stage.Since that period,China has established the Urban Employee Basic Medical Insurance Scheme(since 1994),the Urban Resident Basic Medical Insurance Scheme(since 2007)and the New Rural Cooperative Medical Scheme(since 2003).As a result,the basic medical insurance system now turns back to government’s guidance.It is neither as strictly controlled as it was in the planned economy period,nor is it as laissez-faire in the reform and opening-up period.Rather,the basic medical insurance system is market-driven with fair government intervention.However,an in-depth analysis of the status quo finds that financial expenditure responsibilities of basic medical insurance are still vaguely defined,the division of financial powers and expenditure responsibilities of basic medical insurance between the central government and local authorities remains unclear,and the financial expenditure of basic medical insurance lacks systematic performance evaluation.This dissertation discussed the questions mentioned above in the following three parts.Part one analyzed the financial expenditure responsibilities of basic medical insurance in China.This part began with a comparison of international governments’ responsibilities for financial expenditure of medical and health insurance services,exploring the basic medical insurance running modes under different expenditure burdens so as to provide references for China to learn from foreign experience.Then,took into consideration the public product attribute of basic medical insurance,the socialist welfare attribute of the state and the boundary between government and market activities,the financial expenditure responsibility scope of basic medical insurance in China was theoretically defined.After that,empirical data were used to analyze factors influencing the financial expenditure of basic medical insurance.Part two analyzed the division of financial powers and expenditure responsibilities of basic medical insurance between the central government and local authorities in China.This part was based on the actual situation in China as well as the theory of financial powers and expenditure responsibilities division and analyzed expenditure responsibilities division of basic medical insurance between the central government and local authorities in China.Firstly,the responsible subjects of financial powers and expenditure responsibilities were clarified,and then specific division of responsibilities between the central government and local authorities,such as management of basic medical insurance and financial support,was clarified.To be more specific about responsibility division,basic medical insurance financial expenditure data were used to calculate the proportion of responsibility division from the perspective of making ends meet,thus providing theoretical and practical guide for achieving clear division of responsibilities and coordinated financial powers between the central government and local authorities.A comparison of the newly proposed division strategy in this dissertation between the currently employed division strategy was also conducted.Part three established a framework to evaluate financial expenditure performance of basic medical insurance in China.This part mainly used qualitative analysis method to construct a performance evaluation system.Indicators such as efficiency,health outcomes,regional fairness and economic performance were selected.Empirical data were collected and empirical methods were used to evaluate the performance of basic medical insurance financial expenditure in China,thus providing direction for the establishment of a framework to evaluate the performance of basic medical insurance in China.Based on thorough analysis of these questions,the following conclusions could be drawn.First,according to financial expenditure responsibility scope of basic medical insurance,government’s financial expenditure responsibility can be defined as limited or unlimited.Government that takes limited financial expenditure responsibility usually shares responsibility with society and individuals in fund-raising,while government taking unlimited financial expenditure responsibilities goes to the opposite and assumes almost all the fund-raising duties of basic medical insurance.Given the fact that the introducing of market mechanisms can not only improve the operational efficiency of basic medical insurance but also to a certain extent alleviate government’s financial pressure,limited financial expenditure responsibility is more appropriate for China.Second,a clear division of responsibilities between the central government and local authorities remains the key to safeguarding the running of basic medical insurance.Based on the theory of multi-level public finance,basic medical insurance in China should be regarded as a mixed public product.Therefore,it is more reasonable for the central government and local authorities to share the financial powers and take expenditure responsibilities.In clarification of the specific responsibilities of the central government and local authorities,it is found that compared with the central government,local authorities can better grasp the preferences of local residents while providing basic medical insurance services,so it is more appropriate for local authorities to be responsible for specific implementation of basic medical insurance while macro-responsibilities such as strategy formulation,planning and supervision should be left to the central government.As for the proportion of responsibility division,it is found through analysis of external theory and empirical data that local authorities of the different provinces can show great difference in their ability-to-pay,based on which local authorities can be classified as five groups,unsustainable,short-term sustainable,medium-term sustainable,medium-to-long-term sustainable and long-term sustainable financial expenditure for basic health insurance.Thus,both the central government and local authorities can be classified as five groups based on their ability-to-pay.Third,based on “4E” principles and qualitative research of performance evaluation theory,a performance evaluation system which fits financial expenditure characteristics of basic medical insurance including four indicators(efficiency evaluation,health outcomes evaluation,fairness evaluation and economic performance evaluation)is constructed.And an evaluation of empirical data shows that although financial expenditure of basic medical insurance is fairly low in pure technical efficiency but the health outcomes have improved significantly and have had a positive impact on economic development.Regional financial expenditure of basic medical insurance,however,needs further improvement in its fairness.Based on the analysis results,suggestions concerning how to improve financial expenditure management of basic medical insurance were proposed.First,financial expenditure responsibility scope of basic medical insurance should be defined after comprehensive consideration of the influencing factors.The scale of financial expenditure should match the development of local economy and controlling the excessive growth of financial expenditure of basic medical insurance should consider the aging of population.The second suggestion is about sustainability risk control of financial expenditure of basic medical insurance.The division of financial responsibilities between the central government and local authorities should meet the goal of sustainability and make ends meet by balancing the revenue and expenditure of basic medical insurance.Finally,according to the financial expenditure performance evaluation,improve financial expenditure efficiency of basic medical insurance so as to alleviate the financial pressure,broaden the basic medical insurance financing channels to meet the basic health needs,and balance the central government and local authorities’ financial expenditure of basic medical insurance to improve regional fairness,lay a good foundation for the long-term development of medical and health undertakings such as basic medical insurance,and finally complete the great strategy of “Healthy China”. |
