Process Evaluation On New Cooperative Medical Scheme (NCMS) Intervention Of Three Counties In Ningxia

Background:The New Cooperative Medical Scheme (NCMS) which was launched in China since 2003 has boomed today. In order to improve the equity and sustainability of the NCMS, a new project named "Bringing health care to the vulnerable - developing equitable and sustainable rural health insurance in China and Vietnam", funded by the European Union, was developed in China. The University of Liverpool, AOK Health Insurance Company, Fudan University and other five units participated in this project. According to the project framework, a baseline survey was carried out in three counties of Ningxia Province in 2006 after the project initiation. On the basis of the results, the project team designed an NCMS intervention which was composed of five parts: financing, reimbursement, supervision of designated hospitals and cost control, capacity building and dissemination. The pilot intervention was implemented in the three counties of Ningxia since the beginning of 2007.Objective:According to monitoring the implementation process of the intervention, describe the intervention process, find out the factors which affected the intervention implementation, provide explainable evidences for the impact evaluation of project in the last stage, and provide relative suggestions for intervention adjustment in the following stage of the project, and also offer a reference for decisions on new corporative medical scheme in central and western regions of China.Methods:1. Data source: (1) Collect questionnaires and documents from NCMS offices of the three pilot counties. Data refers to the status of the NCMS schemes, financing, reimbursement, health utilization, etc.(2) Qualitative study: In-depth-interviews and semi-structure interviews were organized with NCMS stakeholders (personnel in health bureau, NCMS office, designated hospitals and farmers) to investigate the operation situation, problems and personnel feelings of the intervention.2. Data analysis:Quantitative data was described with EXCEL. Qualitative data was analyzed with framework-analysis method, also dynamic and resistance analysis method, combined with "process model" of policy implementation was adopt to make further analysis.Results:1. Financing: Individual premium of the three counties has not been increased in 2007. One pilot county has generalized voluntary financing mechanism instead that local cadre collect money door-to-door. The participant rate of the three pilot counties is increased comparing with last year.2. Reimbursement: The schemes of three counties have been adjusted: NCMS package has been enlarged and numbers of designated hospitals have been increased. Because of resource shortage, reimbursement process has no change. The numbers of beneficiaries and actual reimbursement rate of three counties are increased comparing with last year.3. Supervision of designated hospitals and cost control: The NCMS offices of three counties all strengthen the supervision mechanism, and the result becomes one indicator of the performance appraisal framework. One county has carried out the DRG strategy in county-level hospitals.4. Capacity building: Numbers of personnel n NCMS office are increased. With the limitation of fund and technology, information system is developed slowly. A successful workshop on health insurance and NCMS management was held in Ningxia.5. Dissemination: Another successful workshop on NCMS dissemination was held in Ningxia before financing. Marketing principles and technology were introduced.6. Dynamic factors of intervention implementation: national political sustain on NCMS, high attention of local government, increasing serving notion of NCMS office, improvement of farmers' individual consciousness.7. Resistance factors of intervention implementation: lack of fund, human resource and equipments, low level of medical treatment affecting fanners' satisfactory, managers worrying about the sustainability of NCMS, the orientation of NCMS office restricting its supervision function, traditional concept of farmers, achievements view of local government.Suggestions:1. Strengthen the interventions which have being implemented, and discuss further schemes based on making communications with three counties. To the interventions which have difficulties in implementation now, it is better to communicate with local governments and then make a step-by-step scheme.2. Allocating resources properly and insuring resources match to its function.3. Accelerating information system building.4. Improving the level of medical treatment.5. Strictly controlling the medical expenditure increasing irrationality.6. Strengthening dissemination with the principle of adaptation to local conditions.7. Strengthening monitoring and evaluation.8. Establishing laws and regulations on NCMS.