Skip to content

Advertisement

BMC Health Services Research

What do you think about BMC? Take part in

Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

The effects of China’s New Cooperative Medical Scheme on accessibility and affordability of healthcare services: an empirical research in Liaoning Province

BMC Health Services Research201414:388

https://doi.org/10.1186/1472-6963-14-388

Received: 21 February 2013

Accepted: 11 September 2014

Published: 13 September 2014

Abstract

Background

China’s New Cooperative Medical Scheme (NCMS), launched in 2003, was intended to prevent the impoverishment due to catastrophic illness costs. Previous studies have been conducted on the “design flows” of the NCMS, for example, the irrational insurance benefit package. But after several years of implementation, very little has been known about the improvements made by the NCMS and rural residents’ attitudes toward it. This article specifically focused on the improvements of healthcare services and the enrollees’ choices of providers since the implementation of the NCMS in Liaoning province.

Methods

We conducted a one-on-one interview with healthcare officials in order to get a better understanding of the NCMS policies of the local area. We conducted a door-to-door survey in 3 counties, 21 villages and 602 households to gauge population characteristics, respondents’ healthcare preferences, satisfaction levels with providers, and their attitudes towards designated healthcare institutions.

Results

We found that 43.6% of the respondents believed the NCMS brought more convenience to receive healthcare services. 35.2% of the rural residents thought the NCMS work ineffectively, mainly due to the high healthcare costs. 72.3% of the respondents preferred the county hospitals when they got severe diseases, mainly for the reason of better skills and more advanced equipment, while they preferred village clinics (56.5%) and township hospitals (23.2%) when they got minor diseases mainly for the reason of convenience.

Conclusion

We concluded that the NCMS improved the situation of hard to receive healthcare services but did not reduce the high healthcare fees. Furthermore, participants were unsatisfied with the NCMS designated hospitals. Based on our findings, a number of remedial actions were proposed, including redistributing healthcare resources, developing more domestic medical equipment to lower the treatment costs, and establishing a new talent flow mode.

Keywords

Case studyNew Cooperative Medical SchemeDesignated hospitalsInadequate and overly expensive medical services

Background

As one of the largest developing countries in the world, China has been striving to create a universal healthcare system. The healthcare insurance has the potential to prevent the inaccessibility to healthcare services due to financial reasons, since the financial risk of healthcare services is shared among insurance enrollees and the healthcare costs will be reduced as well [1]. Currently, the primary healthcare insurance programs in China could be divided into three categories, namely, the Urban Employee Basic Medical Insurance (UEBMI) for urban employees, the Urban Resident Basic Medical Insurance (URBMI) for urban residents, and the New Cooperative Medical Scheme (NCMS) for rural residents.

According to the 6th national population census in China, by 2010 the total rural population had reached 674 million, accounting for 50.3% of the country’s total population of 1.339 billion. Rural public health has become one of the top priorities in China’s healthcare system, and how to improve rural residents’ health and equalize the public health services has been gaining great attention [2].

Since established in 2003, the NCMS was designed exclusively for the rural population according to their hukou, with the aim of improving accessibility to healthcare services and preventing catastrophic illnesses [35]. Before its implementation, by the early 2000s, 65% of the rural residents requiring hospitalization were either opting not to be admitted or checking themselves out of care before their doctors recommended discharge, with the main reason of financial concerns [6]. And according to the third National Health Service Survey in 2003, 80% of the rural residents were not covered by any form of healthcare insurances and 30% of patients could not afford hospitalization when they needed it [7]. With 304 pilot counties, the NCMS is organized, guided, and largely funded by both central and local governments, and only requiring its participants to pay a small amount of money (approximately US$1.50) to the Bureau of Health in their county government [8]. Instead of at the village or township level, NCMS operates at the county level; thus, it provides a larger risk pool and economies of scale in organization and management [9]. The ministry of health of central and local government agencies is the policy maker and mainstay of NCMS. Additionally, the financing mechanism has delegated the management of the NCMS to local governments, and differences in funds raised and reimbursement rates between regions were permitted [10].

The rural healthcare providers could be classified into county hospitals, township hospitals and village clinics, with the county hospitals on the top and the village clinics at the bottom [11]. In addition, for patients requiring senior healthcare services, a transferal policy has been established to help the patients transfer from designated county hospitals to city/provincial hospitals. Generally, as the funding of the NCMS is based on the county level of governmental organization, it is expected that people will seek healthcare services in designated hospitals, most of which are located within the home county; while for enrollees out-of-county, reimbursement for city services is severely limited [4]. Furthermore, healthcare services are provided through a fee-for-service reimbursement with the focus on inpatient care, and the reimbursement rates vary by different types of care and at different health facilities. In 2007, the NCMS has extended its coverage to outpatient care, with the emphasis on catastrophic outpatient costs, and the reimbursement is made through participants’ Medical Saving Account or pooled funds [12]. In addition, the NCMS only reimburses drugs listed on the National Essential Drug Reimbursement List, services covered by the insurance package, and care sought at state-owned public health facilities. The reimbursement rates, though different in each province, are the highest for care delivered at village/township health centers and the lowest at city/provincial hospitals [13, 14].

Initial success has been observed in the aspect of policy promotion. By 2010, more than 96% of the rural residents were covered by the NCMS [15], and about 90% of the participating rural households expressed their willingness to continue to participate the program [16]. After nine years of implementation, according to the 2012 Report on the Work of the Chinese Government, the NCMS has covered 832 million people, that is 97.5% of rural resident. Furthermore, government contribution to insurance premium increased from 10 RMB (US$1.60) in 2003 to 240 RMB (US$38.51) in 2012; and insurance packages have expanded from covering mainly catastrophic illness to outpatient and prevention care [17].

To date, a number of studies have been conducted on the “design flows” of the NCMS. Yip et al. have demonstrated the irrational NCMS packages that ignored the disease profile and health expenditure pattern of the population, which would limit the effectiveness [18]. But little has been known about how far the NCMS can improve access to healthcare services and the overall effect of the NCMS on the beneficiaries. In our study, we focused on the effects of the NCMS on the healthcare accessibility and affordability, the rural residents’ attitudes toward the designated healthcare institutions and their choices of providers.

We interviewed NCMS policy makers in 19 counties in Liaoning province, as well as the executors of related village, township and county hospitals. In addition, we extensively collected opinions from the primary-level staff on their views of the present rural health policies. Later we randomly selected 3 counties with high, middle and low level of economic development, respectively. We conducted a survey with the rural residents in these counties on their opinions of the NCMS, expecting to find the factors that influence the healthcare service quality and the improvements of the NCMS.

Methods

Study sample

There are 19 counties in Liaoning province, and we subclassified them into 3 groups according to the average income. Dawa County, Changtu County and Xinbin County were selected through stratified sampling. From each of the selected counties, seven villages were randomly chosen. In each county, 30 households were randomly selected. We conducted a door-to-door survey with the target households. The sample size was calculated as 2 ‰ of the total number of households in each area. The survey was conducted with trained interviewers in 3 counties, 21 villages and 630 households. We got 630 questionnaires in total, and 602 were qualified. Informed consent was obtained from all participants following a protocol approved by Ethics Committee of China Medical University.

There were two parts in our study: interview and survey. One-on-one interview was conducted with the health officials with administrative responsibilities at city, county, township and village levels in order to get a better understanding of the local NCMS policies. A door-to-door survey was undertaken with a locally contextualized questionnaire, containing customized question sets designed to gauge population characteristics, respondents’ healthcare preferences, satisfaction levels with providers, and opinions on designated healthcare institutions in general. All the interviewers were graduate students who have received detailed in-person training.

Data analysis

Data extraction was checked through parallel double entry with Epidata 3.0. Demographic characteristics of respondents including age, gender, family size, education background, job, annual income, medical expenses, etc. were described (Table 1). Analyses were performed with SPSS 13.0 and Excel.
Table 1

Basic information of surveyed individuals/families

Variables

 

N

Percentages

SEX

Male

218

36.2

Female

384

63.8

AGE(YEARS)

≤40

110

18.3

40-49

186

30.9

50-59

190

31.6

≥60

116

19.3

FAMILY SIZE (NUMBER OF FAMILY MEMBER)

1

37

6.1

2

124

20.6

3

195

32.4

4

131

21.8

≥5

115

19.1

EDUCATION BACKGROUND

No schooling

68

11.3

Primary school

113

18.8

Junior high school

300

49.8

Senior high school

110

18.3

College/beyond college

11

1.8

JOB

Professionals

48

8.0

Farmers

285

47.3

Unemployed or contract workers

217

36.0

Workers or businessmen

52

8.6

ANNUAL INCOME

≤3000

42

7.0

3000-8000

125

20.8

8000-12000

140

23.3

12000-20000

158

26.2

≥20000

137

22.8

MEDICAL EXPENSES

<500

122

20.3

500-5000

358

59.5

5000-10000

83

13.8

>10000

39

6.5

MEDICAL EXPENSES/ANNUAL INCOME

≤20%

360

59.8

20%-40%

111

18.4

≥40%

131

21.8

Results

General data

In our sample, the two-week prevalence ratea (except chronic diseases) was 12.4%, lower than the national level in 2008 (18.9%); the hospital admission rate was 17.2%; the choices of first clinical hospital were: county hospitals (46.7%), and township hospitals or village clinics (43.3%); 54.8% of the households were diagnosed with chronic diseases, with the cardiovascular diseases being top at 28.9%, followed by diabetes (14.3%), digestive diseases (3.2%), chronic pulmonary diseases (2.4%), lumbar and cervical diseases (2.7%) and mental diseases (1.1%). A considerable number (37.2%) of the surveyed households had at least one family member who had suffered from the diseases requiring high healthcare fees; 5.5% of these families could not afford the high fees and 32.8% could barely make it.

Inadequate and overly expensive healthcare services

According to our study, 24.6% of the participants held that the long waiting time had been the major concern in healthcare services (Figure 1). Other reasons (31.6%) accounting for inadequate healthcare services were: the regular work-and-rest time of designated healthcare institutions is inconvenient for farmers to see a doctor; it is difficult to transfer to another hospital; the medical staff and drugs are inadequate at designated hospitals. In addition, 32.7% of the participants complained of poor accessibility to city hospitals; 25.3% of the participants had poor accessibility to county hospitals; and17.9% of the participants had poor accessibility to township and village hospitals. The reasons for poor accessibility at city hospitals were long waiting time (34.7%), difficult registration (33.6%) and inconvenient transportation (31.8%). When it comes to healthcare expenses, we found 74.9% of the respondents believed that the healthcare fees were far too high, especially the drug prices (78.3%) and check-up fees (61.5%) (Figure 2).
Figure 1

Main reasons for inadequate healthcare services.

Figure 2

Reasons for high healthcare services fees.

The public satisfaction level

Table 2 presented the enrollees’ satisfaction rate of the current NCMS policy and the effect of high healthcare service fees on their level of satisfaction. The majority (68.6%) of participants felt satisfied with the current NCMS policy. And a considerable proportion of enrollees’ compliant of high healthcare service fees, accounting for 73.4%. In addition, among the people believing that the NCMS was barely acceptable or even worse, 82.4% of them held that the healthcare service fees were fairly high.
Table 2

The influence of high healthcare service fees on the NCMS

High healthcare service fees

Satisfaction level with NCMS

Very satisfied

Satisfied

Barely acceptable

Dissatisfied

Very dissatisfied

Total

Yes

69(16.8%)

198(48%)

104(25.3%)

32(7.7%)

9(2.2%)

412(73.4%)

No

41(27.5%)

77(51.5%)

26(17.6%)

5(3.4%)

0(0%)

149(26.6%)

Total

110(19.6%)

275(49%)

130(23.2%)

37(6.6%)

9(1.6%)

561

X2 = 16.2; n = 10;15.99 < P < 18.31;the high medical service is associated with the effect of NCMS (P = 0.9).

The improvements of the NCMS

When asked about the improvements of the NCMS on the inadequate and overly expensive healthcare services, 43.6% of the respondents believed that it had been more convenient to receive healthcare services (Figure 3). In addition, 10.5% of the respondents thought that the NCMS had greatly relieved the financial burden of healthcare services (Figure 4), while 45.8% believed that there was still a wide gap between the final goal and the reality.
Figure 3

The effect of the NCMS on inadequate healthcare services.

Figure 4

The effect of the NCMS on high healthcare service fees.

Designated healthcare institution preferences

The majority (81.9%) of the respondents would prefer to go to the designated healthcare institutions, and 90.7% of the respondents lived nearby these institutions. When asked about where to seek a doctor when they got severe diseases, 72.3% of the respondents preferred the county hospitals, mainly for the reason of better skills and equipment; while they preferred village clinics (56.5%) and township hospitals (23.2%) when they got minor disease mainly for the reason of convenience; 15.4% of the respondents would rather buy some drugs and treat themselves than go to the hospitals (Table 3).
Table 3

Participants’ views and utilization of healthcare institutions

Variables

N

Percentages

Prefer to go to designated hospitals

Yes

462

81.9

No

32

5.7

Only for severe diseases

71

12.6

Satisfied with at least one healthcare institution

Yes

117

20.3

No

460

79.7

Preference when get severe diseases

Municipal hospitals

108

18.0

County hospitals

435

72.3

Township hospitals

29

4.8

Village clinics

14

2.3

Others

16

2.6

Preference when get minor diseases

Municipal hospitals

0

0.0

County hospitals

29

4.9

Township hospitals

138

23.2

Village clinics

337

56.5

Others

92

15.4

The nearest healthcare institution

Designated health institution

495

90.7

Non-designated health institution

51

9.3

Irrational medical treatment

Yes

208

42.9

No

244

50.3

Frequency of minor diseases

No idea

33

6.8

Ofen

159

21.7

Occasionally

242

41.3

Hardly

185

31.6

See a doctor when get minor diseases

Ofen

315

53.8

Occasionally

89

15.2

Hardly

182

31.3

Note: As some respondents did not fill in all the options, the total number of each category is not 602.

Attitudes toward the designated healthcare institutions

In terms of service attitude, village clinics (63.3%) were thought to provide the best service, while county hospitals (21.8%) were voted to provide bad services. With regard to equipment, city and county hospitals were considered better equipped (65.3%) and they were with higher medical skills (58.3%). One interesting finding was that some village clinics seemed to provide some door-to-door services (26.2%), while the majority of designated healthcare institutions did not. In addition, a considerable number of the designated hospitals were considered to have higher drug prices than the average market prices (56.8% of county hospitals; 52.5% of township hospitals; 43% of village hospitals). Details were listed in Table 4.
Table 4

Participants’ opinions on designated healthcare institutions

Variables

 

County hospitals

Township hospitals

Village clinics

 

N

Percentages

N

Percentages

N

Percentages

Service attitude

Good

269

44.7

313

52.0

381

63.3

Average

160

26.6

163

27.1

207

34.4

Bad

131

21.8

45

7.5

25

4.2

Medical equipment

Good

393

65.3

150

24.9

68

11.3

Average

128

21.3

287

47.7

190

31.6

Bad

13

2.2

101

16.8

302

50.2

Skills

Good

351

58.3

115

19.1

95

15.8

Average

117

19.4

310

51.5

165

27.4

Bad

17

2.8

94

15.6

236

39.2

Door-to-door services

Yes

11

1.8

38

6.3

158

26.2

No

518

86.0

564

93.7

444

73.8

Drug prices are higher than the market prices

Yes

342

56.8

316

52.5

259

43.0

No

99

16.4

122

20.3

206

34.2

Note: As some respondents did not fill in all the options, the total number of each category is not 602.

Discussion

Principal findings

Our study provides new evidence on the effect of NCMS on the beneficiaries and their current state of satisfaction. In general, the NCMS policies have enjoyed high satisfaction rate, but many participants believed that there would be a long way in achieving its goal of preventing catastrophic poverty. The high healthcare service fees and inadequate healthcare services are still of great concern. The NCMS reimbursement package could not alleviate the financial pressure due to the high check-up fees and drug prices at the designated hospitals. Even though the village clinics were considered to provide the best healthcare services, people preferred higher level of designated hospitals when they got severe diseases, namely the county or even city hospitals. The long waiting hours and difficult registration process in these hospitals had been complaint constantly.

The effect of the NCMS on healthcare service accessibility

According to our results, the majority of the NCMS enrollees would come to the designated hospitals for medical care when they get sick, and a considerable number of participants believe that seeking medical care has been more convenient. It is consistent with several previous studies [19, 20], reflecting the problem of inadequate healthcare services has been eased to certain extend. As found in our study, over 90% of the participants lived nearby the designated hospitals, indicating that the geographic accessibility has been improved much in the rural area.

Along with the great improvements, nearly one-third of the rural residents believed that the issue of inadequate healthcare services required further improvement, especially in county hospitals. It could be explained by the imbalanced distribution of healthcare resources. In terms of the city hospitals, where there are more advanced equipment and highly skilled providers, the large urban population drives up the overall demand for healthcare services. In that case, the limited city healthcare services may not meet the needs of the rural area. In addition, the weakened social role of township and village clinics will cause a lack of cost-effectiveness and the corresponding social-effectiveness [21], leading to low utilization of the available healthcare resources. Our finding that the rural residents preferred city or county hospitals when they got severe diseases, while they preferred the village clinics or buying drugs themselves when they got minor diseases, reflected the prominent inability of township and village hospitals.

The effect of the NCMS on healthcare service affordability

A large proportion of rural residents believed that the healthcare services were expensive, which reflected the imbalance between healthcare costs and people’s affordability [22]. The longitudinal study from 2003 to 2005 by Chinese Ministry of Health and World Bank indicated that inpatient cost per case increased by 30% after people were insured [23]. In our study, nearly one-fifth of the respondents held that the high healthcare fees led to the ineffectiveness of the NCMS. The high healthcare fees were due to the high drug prices and high check-up expenses. Nearly 60% of the rural residents believed that the drug prices in designated hospitals were higher than the market prices, and the higher level of hospital, the higher the drug prices. In spite of the increasing reimbursement rate, the policy reimbursement rate for inpatient care is much higher than that in the outpatient care. Due to the higher price for inpatient care as well as the existence of reimbursement deductible, the poorer enrollees, especially these with chronic diseases, might not be well protected by the NCMS to receive proper medical care in time due to financial reasons. The poor were more likely to seek informal and less qualified providers, or resort to self-treatment when they were ill [24]. Other studies have also proved that unmet healthcare needs and service avoidance were more prevalent in the lowest socio-economic status households than in the highest socio-economic status households [25, 26]. Our finding provided a hard evidence for the pro-rich inequality for inpatient service utilization proposed by Yuan et al [27].

The NCMS has features like great publicity, quick financing and stable drug prices [28]. However, according to our study, the rural residents had a low level of satisfaction with designated hospitals. Only 20% of the rural residents felt satisfied with their designated hospitals, while nearly half of them believed that designated hospitals had certain irrational medical treatments like over-prescribing drugs. As the NCMS encourages people to seek healthcare services, providers may over-prescribe drugs and high-tech cares due to its fee-for-service payment system and the limited financing for health facilities from the government [29]. Furthermore, 40% of the participants had experienced irrational medical treatments like prescribing expensive drugs or repeated inspections [30]. According to Jiang et al., the overuse of injections, particularly the excessive unrestricted use of multiple injections, has become a big problem at the rural healthcare facilities in Sichuan [31]. The abuse of injections may partially be due to the misbelief that it would be more convenient and efficient than oral medications, but it is also linked with more revenues generated for healthcare facilities and medical stuff [32]. In other words, without proper public education or medical treatment restriction, the NCMS would play a limited role in reducing healthcare expenses.

Policy implications

Redistribute healthcare resources

Rural China has 8.13 hospitals per million people, and 21.35 doctors and 1.75 beds per 1,000 people [33]. As was indicated in our study, the designated hospitals of the NCMS presented different healthcare service qualities and patients were prone to seek medical help form higher level of healthcare institutions like county hospitals instead of village clinics or township hospitals. Despite the government’s effort to restrain costs by encouraging patients to use township health centers, making the copayment amounts lower and patient reimbursement rates higher than at the county hospitals, the township hospitals failed to play its role of delivering rural health care and acting as a referral to the county hospitals. And the effort to promote the reasonable shunt of patients with a distinguishing subsidy turned out to be one of the causes of hard to receive healthcare service for the rural residents [34, 35].In this case, we suggest redistributing healthcare resources according to the coverage radius, population density as well as the general condition of every healthcare institution.

Put more emphasis on medical equipment development

As high check-up fees play a dominant role in expansive healthcare fees, developing domestic medical equipment with low costs and properly allocating them to the rural areas would ease the problem. Furthermore, a standardized and networked electronic diagnosis and medical record system should be applied in different hospitals, which will avoid repeated tests, promote medical resource sharing and facilitate remote diagnosis. It could also benefit the patients who need transferring to higher levels of hospitals. The networked information system would also enable the administrative staff to trace the detailed information on healthcare service conditions in the rural areas.

Establish a new talent flow mode

As indicated from our study, the township and villages hospitals were considered to provide better healthcare services but with lower clinical skills and more inadequate medical knowledge, which was one of the factors leading to irrational drug use. A study by Wang et al. showed that village doctors urgently needed more training on rational drug use [36], however, improving the skills of healthcare personnel was more critical to making full use of the NCMS [37]. To improve the medical skills of the working stuff at these hospitals, a long-lasting new talent flow mode to township and village clinics should be promoted. We suggest establishing a dynamic flow system consisting of medical professionals from city hospitals to county hospitals and from county hospitals to township and village clinics. The excellent medical stuff of every level of health institutions shall take turns working in healthcare institutions of other levels for a fixed period of time. To ensure the initiative of this policy, their performance shall be taken as an important criterion for professional qualification assessment, end-year bonus evaluation and title assessment. Simultaneously, the government shall provide more remedies to attract more medical staff of superior hospitals to rural medical institutions. With better skills, the village and township hospitals could attract more patients for their first visits and enhance their confidence in the hospitals. In addition, the village and township hospitals could exploit their advantages of low price and good service to the full to attract more patients.

Limitations

The study has several limitations. Firstly, due to the limited sample size, certain bias could exist in some of our findings. And as the selection of the respondents focused on certain communities in the 21 villages, and the results may not be generalizable to the entire country, and could not fully represent the rural population. Secondly, some data in out study, like medical expanses, were collected on the basis of personal recall and could be prone to measurement errors. In addition, as we only focused our study in Liaoning province, and the NCMS policies could be somehow different from area to area, some of our findings might be limited to cities sharing similar policies.

Conclusion

Our study suggests that the NCMS improved the situation of hard to receive healthcare services but did not reduce the high healthcare fees. The long waiting time during healthcare services remained to be the major problem in inadequate healthcare services. Furthermore, participants were unsatisfied with the NCMS designated hospitals, with the main reason of high expanses. The data in our study suggest that the designated hospitals of various levels presented different problems in aspects of service attitude, equipment, medical skills, service price, etc. The NCMS is clearly of great importance to reduce inaccessibility and unaffordability of healthcare services with the ultimate goal to reach universal health coverage. To achieve this goal, more studies shall be carried out in different areas to explore a more feasible policy that could be generalized on a broader scale and to get more hints for further policy making.

Endnote

aTwo-week prevalence rate = The number of patients in the first two weeks / The number of surveyed people 100%; the fourth National Health Services Survey showed the two-week prevalence rate in 2008 was 18.9%.

Declarations

Acknowledgements

This study was supported by Science and Techonology Project of Liaoning Province, 2012,”Medical resource distribution equity studies” (#2012225101).

Authors’ Affiliations

(1)
Department of the Health Service Management, China Medical University
(2)
China Medical University seven-year system, China Medical University

References

  1. Yip W, Berman P: Targeted health insurance in a low income country and its impact on access and equity in access: Egypt’s school health insurance. Health Econ. 2001, 10 (3): 207-220. 10.1002/hec.589.View ArticlePubMedGoogle Scholar
  2. The Central People’s Government of the People’s Republic of China: The central finance funding 10.4 billion Yuan for basic public health services. 2009, Government of the People’s Republic of China website. Available: http://www.gov.cn/gzdt/2009-07/06/content_1358394.htm. In Chinese. Accessed 2009 Jul 15Google Scholar
  3. Qiu P, Yang Y, Zhang J, Ma X: Rural-to-urban migration and its implication for new cooperative medical scheme coverage and utilization in China. BMC Public Health. 2011, 11 (1): 520-10.1186/1471-2458-11-520.View ArticlePubMedPubMed CentralGoogle Scholar
  4. Center for China Cooperative Medical Scheme (CCMS): About CCMS: Backgroud (in Chinese). 2005Google Scholar
  5. Wagstaff A, Lindelow M, Shiyong W, Shuo Z: Reforming China’s Rural Health System. 2009, Washington (DC): World BankView ArticleGoogle Scholar
  6. Office of the World Health Organization Representative in China: Social Development Department of China State Council Development Research Center: health, poverty, and economic development. http://www.who.int/macrohealth/action/CMH_China.pdf.
  7. Chinese Ministry of Health Centre for Health Statistical Information: Abstract of the report on the 3rd National Health Service investigation and analysis. Chin Hosp. 2005, 9: 7-15.Google Scholar
  8. Liu Y, Rao K: Providing health insurance in rural China: from research to policy. J Health Polit Policy Law. 2006, 31 (1): 71-92. 10.1215/03616878-31-1-71.View ArticlePubMedGoogle Scholar
  9. You X, Kobayashi Y: The new cooperative medical scheme in China. Health Policy. 2009, 91 (1): 1-9. 10.1016/j.healthpol.2008.11.012.View ArticlePubMedGoogle Scholar
  10. Dai B, Zhou J, Mei YJ, Wu B, Mao Z: Can the New Cooperative Medical Scheme promote rural elders’ access to health-care services?. Geriatr Gerontol Int. 2011, 11 (3): 239-245. 10.1111/j.1447-0594.2011.00702.x.View ArticlePubMedGoogle Scholar
  11. Tian M, Feng D, Chen X, Chen Y, Sun X, Xiang Y, Yuan F, Feng Z: China’s Rural Public Health System Performance: a cross-sectional study. PLoS One. 2013, 8 (12): e83822-10.1371/journal.pone.0083822.View ArticlePubMedPubMed CentralGoogle Scholar
  12. Barber SL, Yao L: Development and status of health insurance systems in China. Int J Health Plann Manag. 2011, 26 (4): 339-356. 10.1002/hpm.1109.View ArticleGoogle Scholar
  13. Babiarz KS, Miller G, Yi H, Zhang L, Rozelle S: China’s new cooperative medical scheme improved finances of township health centers but not the number of patients served. Health Aff. 2012, 31 (5): 1065-1074. 10.1377/hlthaff.2010.1311.View ArticleGoogle Scholar
  14. Babiarz KS, Miller G, Yi H, Zhang L, Rozelle S: New evidence on the impact of China’s New Rural Cooperative Medical Scheme and its implications for rural primary healthcare: multivariate difference-in-difference analysis. BMJ. 2010, 341: C5617-10.1136/bmj.c5617.View ArticlePubMedGoogle Scholar
  15. Zhou Z, Su Y, Gao J, Xu L, Zhang Y: New estimates of elasticity of demand for healthcare in rural China. Health Policy. 2011, 103 (2): 255-265.View ArticlePubMedGoogle Scholar
  16. Qian JC, Gao J, Rao KQ, Adam W, Magnus L: Research on the impact of the New Rural Cooperative Medical Scheme on farmers’ health care utilization. Chin J Health Stat. 2008, 25 (5): 450-454. ChineseGoogle Scholar
  17. Xinhua: Report on the Work of the Chinese Government in Xinhua News2012. 2012, Beijing: Xinhua NewsGoogle Scholar
  18. Yip W, Hsiao WC: Non-evidence-based policy: how effective is China’s new cooperative medical scheme in reducing medical impoverishment?. Soc Sci Med. 2009, 68 (2): 201-209. 10.1016/j.socscimed.2008.09.066.View ArticlePubMedGoogle Scholar
  19. Yi H, Zhang L, Luo R, Liu C: The status quo of the township health center and its functions in the New Cooperative Medical Scheme. Zhongguo Wei Sheng Jing Ji. 2009, 28 (6): 56-58. ChineseGoogle Scholar
  20. Wang X, Sun S, Geng FX: Apply traditional economic theory to explain “hard and expensive access health care” and their causes. Chin Health Resour. 2012, 13 (2): 51-52. ChineseGoogle Scholar
  21. Wang HM: Health Policies in a Great Power. 2006, Beijing: Peking University Press, ChineseGoogle Scholar
  22. Qiu YL, Zhang JW, Xu C, Xu XL, Huang H: Research of satisfactory degree on urban residents health insurance: Tiantai county as an example. Chin J Health Policy. 2009, 2 (2): 11-17. ChineseGoogle Scholar
  23. Statistical information center MoH: Progress and Impact of Chinese New Cooperative Medical Scheme. 2007, Beijing: Beijing Union Medical University PressGoogle Scholar
  24. Okeke TA, Okeibunor JC: Rural–urban differences in health-seeking for the treatment of childhood malaria in south-east Nigeria. Health Policy. 2010, 95 (1): 62-68. 10.1016/j.healthpol.2009.11.005.View ArticlePubMedGoogle Scholar
  25. Philip B, Alan B, Yang D: Understanding variation in the design of China’s New Co-operative Medical System. The China Quarterly. 2009, 198: 304-329. doi:10.1017/S0305741009000320View ArticleGoogle Scholar
  26. Gotsadze G, Zoidze A, Rukhadze N: Household catastrophic health expenditure evidence from Georgia and its policy implications. BMC Health Serv Res. 2009, 9: 69-10.1186/1472-6963-9-69.View ArticlePubMedPubMed CentralGoogle Scholar
  27. Yuan S, Rehnberg C, Sun X, Liu X, Meng Q: Income related inequalities in New Cooperative Medical Scheme: a five-year empirical study of Junan County in China. Int J Equity Health. 2014, 13: 38-10.1186/1475-9276-13-38.View ArticlePubMedPubMed CentralGoogle Scholar
  28. Xu AJ, Zhu N: Research on the affecting factors of hospitalizing behavior for people who participate in the NRCMS. Chin Health Serv Manag. 2012, 29 (6): 446-450. ChineseGoogle Scholar
  29. Liang X, Jin C, Wang L, Wei L, Tomson G, Rehnberg C, Wahlstrom R, Petzold M: Unnecessary use of antibiotics for inpatient children with pneumonia in two counties of rural China. Int J Clin Pharm. 2011, 33 (5): 750-754. 10.1007/s11096-011-9535-9.View ArticlePubMedGoogle Scholar
  30. Yan Z, Zhou J: Current situation of the new cooperative medical scheme in Anhui province. Applied journal of general practice. 2008, 6 (2): 292-293. ChineseGoogle Scholar
  31. Jiang Q, Yu B, Ying G, Liao J, Gan H, Blanchard J, Zhang J: Outpatient prescription practices in rural township health centers in Sichuan Province, China. BMC Health Serv Res. 2012, 12: 324-10.1186/1472-6963-12-324.View ArticlePubMedPubMed CentralGoogle Scholar
  32. Xiang L, Luo W: The analysis of drug over-use caused by CMS in rural health organizations in impoverished areas. Chin Rural Health Serv Adm. 2002, 22 (6): 25-28.Google Scholar
  33. China statistical yearbook: Chinese National Bureau of Statistics. 2009, Beijing, http://www.stats.gov.cn/tjsj/ndsj/2009/indexch.htm.Google Scholar
  34. Su R, Zhang Y, Li J: Mixed payment is an appropriate choice for the new type of rural cooperative medical care. Health Econ Res. 2006, 8: 17-18. ChineseGoogle Scholar
  35. Lang X, Lu B: The Operation Situation of NRCMS,the Satisfaction Situation of Participant Farmers and its Factors——Taking Nanjing Suburbs as Example. China Rural Survey. 2010, 4: 63-73, 80. ChineseGoogle Scholar
  36. Wang H, Zhang L, Yip W, Hsiao W: An experiment in payment reform for doctors in rural China reduced some unnecessary care but did not lower total costs. Health Aff. 2011, 30 (12): 2427-2436. 10.1377/hlthaff.2009.0022.View ArticleGoogle Scholar
  37. Wang X, Zheng A: Ideas about the protection of high-quality medical resources in rural areas. Chinese Health Economics. 2012, 31 (5): 54-55. ChineseGoogle Scholar
  38. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/14/388/prepub

Copyright

© Wang et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Advertisement