中国新型农村合作医疗制度可持续发展研究
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摘要
研究背景
农民、农村及农业问题(即“三农问题”)长期以来都是中国一个带有全局性、战略性的问题。虽然中国的改革是从农村开始的,但是发展至今,“三农问题”仍然是中国政府非常关注的一个问题。中国是一个农业大国,如果农民的健康不能得到全面改善,中国经济的发展势必将受到很大的影响和制约。
疾病风险是一种不确定的风险。对于收入水平还比较低的农民来说,疾病风险往往显得更大。但是目前的情况是,由于城乡二元结构的影响,我国大多数农村居民没有医疗保障,这不仅导致我国卫生筹资体制呈现高度不公平性,而且直接或间接地导致了农村医疗服务体系的运转不良,致使疾病成为农村居民贫困的重要因素之一,“因病致贫”、“因病返贫”的现象依然十分严重。广大农民陷入了不敢生病、不能生病而且往往多病的困境中,他们迫切需要一定程度的医疗保障。
合作医疗是中国农村的基本医疗保障制度之一,但这一制度正面临着生存和发展的困境。在20世纪60～70年代,合作医疗曾经惠及大多数农村居民,被世界卫生组织和世界银行誉为“以最少投入获得了最大健康收益”的“中国模式”。然而,改革开放之后,合作医疗制度迅速衰落,仅在少数地区得以残存,覆盖面也极为狭窄。90年代以来,我国政府试图重建和恢复农村合作医疗,但是并没有达到预期的效果,更没有实现1997年1月中共中央、国务院提出的“力争到2000年在农村多数地区建立起各种形式的合作医疗”目标。实际上,20世纪90年代中期,一些乡村在政策推动下就开始了试点,但到90年代末或新世纪之初就陷入了步履艰难、徘徊不前的不良局面。
面对严峻的农村卫生形势,农民的医疗保障问题被提上重要议事日程。2002年中共中央、国务院做出《关于进一步加强农村卫生工作的决定》,接着卫生部、民政部和财政部又联合颁发了《关于进一步做好新型农村合作医疗试点工作的指导意见》,要求建立新型农村合作医疗制度。自试点以来,在各地也取得了一定的成效。但是,多项研究也表明,在试点工作中存在和暴露出许多问题。同样,这项制度以后的发展能否走上正轨,会不会出现春办秋黄,前试后垮,大起大落的现象呢?这就需要我们从历史的角度去获取经验教训,并分析新型农村合作医疗制度可持续发展的现实制约因素,从而探索出一条有利于新型农村合作医疗制度可持续发展的路径。
研究目标
总目标
本研究拟对新型农村合作医疗制度作全面分析,研究新型农村合作医疗试点工作中存在的问题及制约可持续发展的影响因素,探讨其产生根源,总结历史经验,提出在社会主义市场经济条件下促进新型农村合作医疗可持续发展的策略和政策建议,为政府宏观调控与微观管理提供政策依据。
具体目标
1.从宏观上分析、评价我国农村合作医疗制度的历史沿革,并阐述目前推行新型农村合作医疗制度的必要性、迫切性、艰巨性、可行性,以及具有的发展潜力和发展趋势。
2.研究新型农村合作医疗制度可持续发展所需要的理论视角,分析新农合筹资的影响因素,探讨其政策基础和对解决“因病致贫”、“因病返贫”问题的作用机制。
3.研究新型农村合作医疗的现状及存在的问题,分析新型农村合作医疗可持续发展的制约因素和根源,探讨可持续发展的必要支撑条件。
4.探索在社会主义市场经济条件下既具有理论依据,又对促进新农合可持续发展具有实际指导意义的策略和政策建议。
研究方法
1.理论分析与实证研究相结合:历史回顾和现状评价相结合;归纳分析与演绎分析相结合;宏观分析与微观分析相结合。
2.文献法:文献复习,对国内外现有或已有的与新型和传统农村合作医疗制度有关的研究进行文献检索和分析。
3.制度经济学分析方法:分析制度环境变迁等对合作医疗制度的影响。
4.案例研究:选择宁夏新型农村合作医疗的运行状况做为典型案例,进行分析和研究。
研究内容
1.我国农村合作医疗制度的发展历程及历史评判
2.国外农村医疗保障制度的发展经验与启示
3.新型农村合作医疗制度研究所需要的理论视角
4.新型农村合作医疗制度筹资影响因素
5.当前我国新型农村合作医疗的主要模式
6.新型农村合作医疗运行现状研究
7.新型农村合作医疗制度可持续发展需配套改革的任务
8.新型农村合作医疗制度可持续发展制约因素
研究的特色与创新之处
本研究针对现实中具有重大意义的新型农村合作医疗制度的可持续发展进行研究,在研究领域和选题角度上,与国家农村卫生发展相关政策紧密结合,与时俱进,其特色与创新之处主要体现在以下几点:
1.多种方法综合集成,做出比较系统的理论分析和案例研究。
2.利用制度经济学的理论与方法分析制度环境变迁对农村合作医疗制度的影响,从制度设计、制度冲突、制度真空、制度变迁、制度配置、制度效率等角度分析农村合作医疗制度的发展与演变。
3.提出在新型农村合作医疗实施中,应发展社区互助补充医疗,与农村医疗救助相衔接,加强城乡医疗保障体系的衔接,加强法规制度建设和技术支持。为保证新型农村合作医疗的参保率、筹资水平、减少“逆选择”等,应实行强制参加原则。
主要结果
1.我国农村合作医疗的发展经历了萌芽阶段(1938年～1955年)、形成阶段(1955年～文化大革命前)、发展与鼎盛阶段(“文革”时期～1978年)、衰落阶段(1978年～1980年代末)和恢复阶段(20世纪90年代以来)。
2.我国传统农村合作医疗衰落的原因可以从二元经济社会结构对农村医疗保障制度变迁的影响、农村经济社会环境变化的影响、合作医疗制度本身的缺陷及改革初期思想的混乱这四个方面做出分析。
3.阐述了建立新型农村合作医疗制度的必要性、迫切性、艰巨性和可行性,当前社会各界必须充分认识到这一点。
4.分析了新型农村合作医疗制度的政策基础,阐述了建立新型农村合作医疗制度对解决农村居民“因病致贫”和“因病返贫”问题的作用机制。
5.研究新型农村合作医疗制度需要从社区筹资理论、制度经济学理论、风险管理理论等理论视角来分析,并探讨新农合中政府干预必要性的理论依据。
6.新型农村合作医疗制度的筹资影响因素包括健康、政治、经济、社会、文化及制度本身的设计等因素。
7.当前我国各地新型农村合作医疗的主要模式有以下几种,即大病住院农村合作医疗模式、改良式农村合作医疗模式、个人帐户与县(或乡镇)统筹相结合的农村合作医疗模式、家庭帐户与社会统筹相结合的农村合作医疗模式以及商业保险公司多形式参与农村合作医疗模式。其中,大病住院农村合作医疗模式是目前比较普遍的一种运行模式。
8.我国东、中、西部地区新型农村合作医疗试点显示在参保率和补偿率、服务利用和基金管理等方面存在着差异。其中参保率各地比较接近,补偿率随着医疗机构的层次降低而增加。中部和西部最通常被利用的服务机构是乡镇卫生院,而东部地区县级医疗机构的住院比例则比较高。在基金管理方面,东部地区风险基金占筹资基金的比例高于中部和西部地区。
9.宁夏的新型农村合作医疗已经逐步建立并在不断发展,各级政府给予了高度重视和支持,参合农民均不同程度的享受到了新型农村合作医疗带来的益处。存在的主要问题是:筹资成本居高不下;农民的参合率相对较低,对新型农村合作医疗的认知程度较低;各地对供方缺乏约束措施和监控手段,导致医疗费用上涨过快,不利于基金的风险控制。
10.新型农村合作医疗试点中存在的可持续发展制约因素主要包括:
(1)各级政府责任落实问题
(2)农民的支付能力、支付意愿
(3)自愿缴费与逆选择问题
(4)疾病风险控制、道德风险控制和卫生服务筹资公平性之间的矛盾
(5)保大病、保门诊利弊各存
(6)法规制度建设滞后,管理和监督不规范
(7)医疗服务提供者的定点问题
(8)农民的信任问题
(9)传统文化的影响
(10)农村人口老龄化的影响
(11)未参合农民的假冒及滥用现象
11.新型农村合作医疗制度的可持续发展对我国当前农村卫生工作提出了配套改革的任务、要求和挑战,应加强新型农村合作医疗与农村医疗救助的衔接,加强城乡医疗保障体系的衔接,加强法规制度建设和技术支持等。
建议
1.明确政府的职责
2.实行“强制”参加原则,减少需方“逆选择”行为
3.加快新型农村合作医疗的立法进程
4.建立合理的新型农村合作医疗筹资和补偿机制
5.发展社区互助补充医疗,倡导制度模式的多样化
6.加强新型农村合作医疗的广泛宣传,提升农民的信任度
7.大力推进农村“四个体系”改革
8.有效控制非参合人员的假冒及滥用现象
9.加强新型农村合作医疗信息化建设
10.在贫困地区实施农村医疗救助
11.大力发展农村经济
Background
The problem about peasant, countryside and agriculture has been a comprehensive and strategic issue of China for a long time. Although the reform of China was started from the countryside, in the present this problem is still the one to which Chinese government should pay the great attention. We know China is a great country of agriculture. If the health condition of peasants can not be improved roundly, the development of Chinese economy will meet the enormous influence and restriction.
The risk of illness is uncertain. It should be more dangerous to those peasants who have the lower incomes. But the present situation is that the most part of Chinese peasants can not obtain the medical security because of the affection of structure difference between cities and countries, which has already caused not only the great inequity of Chinese system of health funds raising but also the worse operation of rural medical service system directly or indirectly. The result of this situation is that illness becomes the one important reason of peasant poverty. It is still very severe that peasants become poor because of diseases and fall into the poverty again because of diseases. Most of peasants are in the condition that they are afraid of diseases and can not afford the diseases. But they often suffered from diseases. They need the health security urgently.
Rural cooperative medical scheme is the one basic policy of Chinese rural medical security. But now this policy is confronted with the conjuncture of survival and development. In 1960s-1970s, it once brought the great benefits to most of peasants and was also called Chinese Model by WHO and World Bank because of its biggest benefits and the least investments. However, after reforming and opining the door, this scheme began to decline very quickly and it was only reserved in the less part of China and the covering range was also very narrow. Since 1990s, Chinese government has already tried to rebuild and recover this scheme. But it did not obtain the prospective effect, and even did not get the target put forward by the Chinese government and State Department in January of 1997, which was that we should try to build the more kinds of cooperative medical system in the most part of rural areas before 2000. In fact, in the middle time of 1990s, some rural areas began to do the pilot works according to the policy, but in the end of 1990s and at the beginning of 2000s these works fell into the awful situation because of many factors, even were blocked.
Confronted with such a severe condition of rural health, Chinese government put the problem of peasant medical security to the important schedule of official business. In 2002 Chinese government and State Department published the decision about strengthening rural health work. Afterwards, Ministry of health, Ministry of civil administration and Ministry of finance published the instruction about developing experimental work of new rural cooperative medical schemes (NRCMSs) and required to build NRCMSs. Since the experimental works, many areas have got the considerable effect. But many researches also showed that there were still many problems in experimental works. Furthermore, it is still uncertain whether this policy may come into the normal track and can be implemented fluently. We should obtain experiences and lessons from the standpoint of history and analyze the influencing factors of sustainable development of NRCMSs so that we can explore the new path to develop NRCMSs.
Objectives
General objectives
This paper pretended to analyze NRCMSs comprehensively, research the problems in the experimental works of NRCMSs and influencing factors which restricted the sustainable development of NRCMSs, explore the rootstock, generalize the historic experiences, put forward the strategies and policy advices to accelerate the sustainable development of NRCMSs in the condition of socialistic market economy and provide the policy evidences for the macroscopical adjusting and microcosmic administration of Chinese government.
Concrete objectives
I. From the macroscopical standpoint, analyzed and evaluated the historical evolution of Chinese rural cooperative medical schemes and expounded the necessity, imminence, hardship and feasibility of popularizing NRCMSs in the present situation and discussed the development potential and tendency of NRCMSs .
2. Researched the theories which should be necessary to research the sustainable development of NRCMSs , analyzed the influential factors of raising funds of NRCMSs and discussed the policy foundation of NRCMSs and operation mechanism to resolve the problem that peasants became poor because of diseases and fell into the poverty again because of diseases.
3. Study the present situation and problems of NRCMSs, Analyzed the different influential factors and rootstock of supporting sustainable development of NRCMSs and elaborated necessary conditions of supporting sustainable development of NRCMSs.
4. Explored the academic evidences and policy advices which had the theoretical evidences and the actual guiding significance to accelerate the sustainable development of NRCMSs in the condition of socialistic market economy.
Methods
1. Method of combination of theory analysis and demonstration research, which included the combination of history retrospection and actuality evaluation, the combination of conclusion analysis and deduction analysis, the combination of macroscopical analysis and microcosmic analysis.
2. Method of references review. This paper retrospected the references about rural cooperative medical systems and researched and analyzed these materials.
3. Method of system economics. This paper used this method to analyze the effect of evolution of system environment on NRCMSs.
4. Method of case study. This dissertation chose the typical case of NRCMSs of Ningxia to analyze and research NRCMSs.
Contents
1. The development course and historical appraisal of traditional rural cooperative medical schemes of China.
2. The development experiences and apocalypse of rural health security systems of other foreign countries.
3. The theoretical viewpoint which are necessary to the research of NRCMSs.
4. The influential factors of fund raising of NRCMSs.
5. The main operation model of NRCMSs of China in the present.
6. The research about the actual situation of operation of NRCMSs.
7. The reformation duties which should be necessary to the sustainable development of NRCMSs.
8. The influential factors of sustainable development of NRCMSs.
Characteristic and Innovative points of research
This research aimed at the sustainable development of NRCMSs which had the great significance in the present society. It had the tight connection with relative policies of rural health development of China. It had its own characteristic in the study field and selection point of view. It had the next innovation points.
1. It used several comprehensive methods to do the systemic analysis and research of theories and cases.
2. This dissertation used the principle of system economics to analyze the effects which the change of system environment had on rural cooperative medical system. From the viewpoints of system project, system confliction, system vacuum, system change, system configuration and system efficiency, it explored the development and evolution of NRCMSs.
3. It thought that we should develop the community mutual and complementary health system and connect NRCMSs with rural health salvation system, and strengthen the connection of health security system between cities and counties, and strengthen the law construction and technology support. In order to ensure the ratio of joining NRCMSs and fund raising level and to reduce the adverse selection, we should implement the principle that all peasants must join NRCMSs.
Main results
1. The development process of Chinese rural cooperative medical schemes included the germination phase (from 1938 to 1955), the form phase (from 1955 to 1966), the development and blossom phase (from 1966 to 1978), the eclipse phase (from 1978 to the end of 1980s) and the recover phase (from 1990 to 2002).
2. The reasons of decline of traditional rural cooperative medical schemes included the affection of structure difference between cities and countries, the environmental change of rural economy and society, the inherent flaw of system itself and the thought confusion at the beginning of reform.
3. It specified the necessity, imminence, hardship and feasibility of the construction of NRCMSs. Our society should cognize this situation roundly.
4. The dissertation analyzed the policy foundation and operation mechanism of NRCMSs and thought that the objective of building NRCMSs should be to prevent peasants from becoming poor because of illness and prevent them from falling into poverty again because of disease.
5. This dissertation thought that we should research NRCMSs from some theoretical viewpoints, for example, theory of community fund raising, theory of system economics, theory of risk management. It also explored the academic evidences of necessity of government interference.
6. The influential factors of fund raising of NRCMSs were composed of health factors, politics factors, economy factors, society factors, culture factors and project of system.
7. The models of NRCMSs were composed of inpatient management pattern, improvement management pattern, cooperative management pattern of individual account and county account, cooperative management pattern of family account and social fund raising, management pattern of insurance company. In these models, inpatient management pattern is the main model.
8. The experimental works showed that there were some differences about attending ratio, compensation ratio, services utilization and funds administration among the north part, middle part and west part of China. Attending ratio of three regions have no the great difference. Compensation ratio is relatively higher in the health institutions with the lower grade. The hospitals of townships are greatly utilized in the middle and west areas of China. But the hospitals of counties are greatly utilized in the east part of China. As for the fund management, the proportion of risk fund of the health finance in the east region is higher than that in the west and middle region.
9. The NRCMSs of Ningxia has obtained the gradual development. The government of Ningxia paid the great attention to this system. Peasants got the more benefits from NRCMSs. But there were still some problems. For example, the higher cost of fund raising, the lower attending ration, the lower cognition of peasants and the lack of restrition and supervision to health institution, which caused the fast increasing of medical fees and was adverse to risk control of funds.
10. The main influential factors of sustainable development of NRCMSs included the next points.
(1) The problem of duty fulfillment of different governments.
(2) The ability and aspiration of payment of peasants.
(3) The manner of voluntary payment and the problem of adverse selection.
(4) The contradiction among illness risk control and moral risk control and justice of raising funds of health service.
(5) There were not only advantages but also disadvantages about the severe illness insurance and outpatient insurance.
(6) The establishment of relative laws was late to NRCMSs .The administration and supervision of insurance system were nonstandard.
(7) How to choose the medical service organizations of NRCMSs.
(8) Faith problem of peasants.
(9) The effect of traditional culture on the behavior of peasants.
(10) The effect of rural oldest-old on the NRCMSs.
(11) The phenomena of fraud and abuse among those peasants who do not take part in NRCMSs.
11. The sustainable development of NRCMSs put forward the new duties and requirements and challenges to matching reform of rural health work of new time. We should connect NRCMSs with rural health salvation system, and strengthen the connection of health security system between cities and counties, and strengthen the law construction and technology support.
Suggestions
1. Confirming the duty of government.
2. Implementation of compulsion principle of attending NRCMSs and decreasing the phenomena of adverse selection.
3. Accelerating the process of formulating laws of NRCMSs.
4. Building the rational mechanism of raising funds and compensation.
5. Developing the mutual and complementary health of community and advocating the attempt and multiplicity of system model.
6. Enlarging propaganda and strengthening the faith of peasants.
7. Boosting the associated reforming of medical treatment, health insurance, curative and public health.
8. Controlling the phenomena of fraud and abuse effectively.
9. Strenghtening the information and network construction of NRCMSs.
10. Implementation of rural health salvation system in the poor areas.
11. Developing the rural economy greatly.
农民、农村及农业问题(即“三农问题”)长期以来都是中国一个带有全局性、战略性的问题。虽然中国的改革是从农村开始的,但是发展至今,“三农问题”仍然是中国政府非常关注的一个问题。中国是一个农业大国,如果农民的健康不能得到全面改善,中国经济的发展势必将受到很大的影响和制约。
疾病风险是一种不确定的风险。对于收入水平还比较低的农民来说,疾病风险往往显得更大。但是目前的情况是,由于城乡二元结构的影响,我国大多数农村居民没有医疗保障,这不仅导致我国卫生筹资体制呈现高度不公平性,而且直接或间接地导致了农村医疗服务体系的运转不良,致使疾病成为农村居民贫困的重要因素之一,“因病致贫”、“因病返贫”的现象依然十分严重。广大农民陷入了不敢生病、不能生病而且往往多病的困境中,他们迫切需要一定程度的医疗保障。
合作医疗是中国农村的基本医疗保障制度之一,但这一制度正面临着生存和发展的困境。在20世纪60～70年代,合作医疗曾经惠及大多数农村居民,被世界卫生组织和世界银行誉为“以最少投入获得了最大健康收益”的“中国模式”。然而,改革开放之后,合作医疗制度迅速衰落,仅在少数地区得以残存,覆盖面也极为狭窄。90年代以来,我国政府试图重建和恢复农村合作医疗,但是并没有达到预期的效果,更没有实现1997年1月中共中央、国务院提出的“力争到2000年在农村多数地区建立起各种形式的合作医疗”目标。实际上,20世纪90年代中期,一些乡村在政策推动下就开始了试点,但到90年代末或新世纪之初就陷入了步履艰难、徘徊不前的不良局面。
面对严峻的农村卫生形势,农民的医疗保障问题被提上重要议事日程。2002年中共中央、国务院做出《关于进一步加强农村卫生工作的决定》,接着卫生部、民政部和财政部又联合颁发了《关于进一步做好新型农村合作医疗试点工作的指导意见》,要求建立新型农村合作医疗制度。自试点以来,在各地也取得了一定的成效。但是,多项研究也表明,在试点工作中存在和暴露出许多问题。同样,这项制度以后的发展能否走上正轨,会不会出现春办秋黄,前试后垮,大起大落的现象呢?这就需要我们从历史的角度去获取经验教训,并分析新型农村合作医疗制度可持续发展的现实制约因素,从而探索出一条有利于新型农村合作医疗制度可持续发展的路径。
研究目标
总目标
本研究拟对新型农村合作医疗制度作全面分析,研究新型农村合作医疗试点工作中存在的问题及制约可持续发展的影响因素,探讨其产生根源,总结历史经验,提出在社会主义市场经济条件下促进新型农村合作医疗可持续发展的策略和政策建议,为政府宏观调控与微观管理提供政策依据。
具体目标
1.从宏观上分析、评价我国农村合作医疗制度的历史沿革,并阐述目前推行新型农村合作医疗制度的必要性、迫切性、艰巨性、可行性,以及具有的发展潜力和发展趋势。
2.研究新型农村合作医疗制度可持续发展所需要的理论视角,分析新农合筹资的影响因素,探讨其政策基础和对解决“因病致贫”、“因病返贫”问题的作用机制。
3.研究新型农村合作医疗的现状及存在的问题,分析新型农村合作医疗可持续发展的制约因素和根源,探讨可持续发展的必要支撑条件。
4.探索在社会主义市场经济条件下既具有理论依据,又对促进新农合可持续发展具有实际指导意义的策略和政策建议。
研究方法
1.理论分析与实证研究相结合:历史回顾和现状评价相结合;归纳分析与演绎分析相结合;宏观分析与微观分析相结合。
2.文献法:文献复习,对国内外现有或已有的与新型和传统农村合作医疗制度有关的研究进行文献检索和分析。
3.制度经济学分析方法:分析制度环境变迁等对合作医疗制度的影响。
4.案例研究:选择宁夏新型农村合作医疗的运行状况做为典型案例,进行分析和研究。
研究内容
1.我国农村合作医疗制度的发展历程及历史评判
2.国外农村医疗保障制度的发展经验与启示
3.新型农村合作医疗制度研究所需要的理论视角
4.新型农村合作医疗制度筹资影响因素
5.当前我国新型农村合作医疗的主要模式
6.新型农村合作医疗运行现状研究
7.新型农村合作医疗制度可持续发展需配套改革的任务
8.新型农村合作医疗制度可持续发展制约因素
研究的特色与创新之处
本研究针对现实中具有重大意义的新型农村合作医疗制度的可持续发展进行研究,在研究领域和选题角度上,与国家农村卫生发展相关政策紧密结合,与时俱进,其特色与创新之处主要体现在以下几点:
1.多种方法综合集成,做出比较系统的理论分析和案例研究。
2.利用制度经济学的理论与方法分析制度环境变迁对农村合作医疗制度的影响,从制度设计、制度冲突、制度真空、制度变迁、制度配置、制度效率等角度分析农村合作医疗制度的发展与演变。
3.提出在新型农村合作医疗实施中,应发展社区互助补充医疗,与农村医疗救助相衔接,加强城乡医疗保障体系的衔接,加强法规制度建设和技术支持。为保证新型农村合作医疗的参保率、筹资水平、减少“逆选择”等,应实行强制参加原则。
主要结果
1.我国农村合作医疗的发展经历了萌芽阶段(1938年～1955年)、形成阶段(1955年～文化大革命前)、发展与鼎盛阶段(“文革”时期～1978年)、衰落阶段(1978年～1980年代末)和恢复阶段(20世纪90年代以来)。
2.我国传统农村合作医疗衰落的原因可以从二元经济社会结构对农村医疗保障制度变迁的影响、农村经济社会环境变化的影响、合作医疗制度本身的缺陷及改革初期思想的混乱这四个方面做出分析。
3.阐述了建立新型农村合作医疗制度的必要性、迫切性、艰巨性和可行性,当前社会各界必须充分认识到这一点。
4.分析了新型农村合作医疗制度的政策基础,阐述了建立新型农村合作医疗制度对解决农村居民“因病致贫”和“因病返贫”问题的作用机制。
5.研究新型农村合作医疗制度需要从社区筹资理论、制度经济学理论、风险管理理论等理论视角来分析,并探讨新农合中政府干预必要性的理论依据。
6.新型农村合作医疗制度的筹资影响因素包括健康、政治、经济、社会、文化及制度本身的设计等因素。
7.当前我国各地新型农村合作医疗的主要模式有以下几种,即大病住院农村合作医疗模式、改良式农村合作医疗模式、个人帐户与县(或乡镇)统筹相结合的农村合作医疗模式、家庭帐户与社会统筹相结合的农村合作医疗模式以及商业保险公司多形式参与农村合作医疗模式。其中,大病住院农村合作医疗模式是目前比较普遍的一种运行模式。
8.我国东、中、西部地区新型农村合作医疗试点显示在参保率和补偿率、服务利用和基金管理等方面存在着差异。其中参保率各地比较接近,补偿率随着医疗机构的层次降低而增加。中部和西部最通常被利用的服务机构是乡镇卫生院,而东部地区县级医疗机构的住院比例则比较高。在基金管理方面,东部地区风险基金占筹资基金的比例高于中部和西部地区。
9.宁夏的新型农村合作医疗已经逐步建立并在不断发展,各级政府给予了高度重视和支持,参合农民均不同程度的享受到了新型农村合作医疗带来的益处。存在的主要问题是:筹资成本居高不下;农民的参合率相对较低,对新型农村合作医疗的认知程度较低;各地对供方缺乏约束措施和监控手段,导致医疗费用上涨过快,不利于基金的风险控制。
10.新型农村合作医疗试点中存在的可持续发展制约因素主要包括:
(1)各级政府责任落实问题
(2)农民的支付能力、支付意愿
(3)自愿缴费与逆选择问题
(4)疾病风险控制、道德风险控制和卫生服务筹资公平性之间的矛盾
(5)保大病、保门诊利弊各存
(6)法规制度建设滞后,管理和监督不规范
(7)医疗服务提供者的定点问题
(8)农民的信任问题
(9)传统文化的影响
(10)农村人口老龄化的影响
(11)未参合农民的假冒及滥用现象
11.新型农村合作医疗制度的可持续发展对我国当前农村卫生工作提出了配套改革的任务、要求和挑战,应加强新型农村合作医疗与农村医疗救助的衔接,加强城乡医疗保障体系的衔接,加强法规制度建设和技术支持等。
建议
1.明确政府的职责
2.实行“强制”参加原则,减少需方“逆选择”行为
3.加快新型农村合作医疗的立法进程
4.建立合理的新型农村合作医疗筹资和补偿机制
5.发展社区互助补充医疗,倡导制度模式的多样化
6.加强新型农村合作医疗的广泛宣传,提升农民的信任度
7.大力推进农村“四个体系”改革
8.有效控制非参合人员的假冒及滥用现象
9.加强新型农村合作医疗信息化建设
10.在贫困地区实施农村医疗救助
11.大力发展农村经济
Background
The problem about peasant, countryside and agriculture has been a comprehensive and strategic issue of China for a long time. Although the reform of China was started from the countryside, in the present this problem is still the one to which Chinese government should pay the great attention. We know China is a great country of agriculture. If the health condition of peasants can not be improved roundly, the development of Chinese economy will meet the enormous influence and restriction.
The risk of illness is uncertain. It should be more dangerous to those peasants who have the lower incomes. But the present situation is that the most part of Chinese peasants can not obtain the medical security because of the affection of structure difference between cities and countries, which has already caused not only the great inequity of Chinese system of health funds raising but also the worse operation of rural medical service system directly or indirectly. The result of this situation is that illness becomes the one important reason of peasant poverty. It is still very severe that peasants become poor because of diseases and fall into the poverty again because of diseases. Most of peasants are in the condition that they are afraid of diseases and can not afford the diseases. But they often suffered from diseases. They need the health security urgently.
Rural cooperative medical scheme is the one basic policy of Chinese rural medical security. But now this policy is confronted with the conjuncture of survival and development. In 1960s-1970s, it once brought the great benefits to most of peasants and was also called Chinese Model by WHO and World Bank because of its biggest benefits and the least investments. However, after reforming and opining the door, this scheme began to decline very quickly and it was only reserved in the less part of China and the covering range was also very narrow. Since 1990s, Chinese government has already tried to rebuild and recover this scheme. But it did not obtain the prospective effect, and even did not get the target put forward by the Chinese government and State Department in January of 1997, which was that we should try to build the more kinds of cooperative medical system in the most part of rural areas before 2000. In fact, in the middle time of 1990s, some rural areas began to do the pilot works according to the policy, but in the end of 1990s and at the beginning of 2000s these works fell into the awful situation because of many factors, even were blocked.
Confronted with such a severe condition of rural health, Chinese government put the problem of peasant medical security to the important schedule of official business. In 2002 Chinese government and State Department published the decision about strengthening rural health work. Afterwards, Ministry of health, Ministry of civil administration and Ministry of finance published the instruction about developing experimental work of new rural cooperative medical schemes (NRCMSs) and required to build NRCMSs. Since the experimental works, many areas have got the considerable effect. But many researches also showed that there were still many problems in experimental works. Furthermore, it is still uncertain whether this policy may come into the normal track and can be implemented fluently. We should obtain experiences and lessons from the standpoint of history and analyze the influencing factors of sustainable development of NRCMSs so that we can explore the new path to develop NRCMSs.
Objectives
General objectives
This paper pretended to analyze NRCMSs comprehensively, research the problems in the experimental works of NRCMSs and influencing factors which restricted the sustainable development of NRCMSs, explore the rootstock, generalize the historic experiences, put forward the strategies and policy advices to accelerate the sustainable development of NRCMSs in the condition of socialistic market economy and provide the policy evidences for the macroscopical adjusting and microcosmic administration of Chinese government.
Concrete objectives
I. From the macroscopical standpoint, analyzed and evaluated the historical evolution of Chinese rural cooperative medical schemes and expounded the necessity, imminence, hardship and feasibility of popularizing NRCMSs in the present situation and discussed the development potential and tendency of NRCMSs .
2. Researched the theories which should be necessary to research the sustainable development of NRCMSs , analyzed the influential factors of raising funds of NRCMSs and discussed the policy foundation of NRCMSs and operation mechanism to resolve the problem that peasants became poor because of diseases and fell into the poverty again because of diseases.
3. Study the present situation and problems of NRCMSs, Analyzed the different influential factors and rootstock of supporting sustainable development of NRCMSs and elaborated necessary conditions of supporting sustainable development of NRCMSs.
4. Explored the academic evidences and policy advices which had the theoretical evidences and the actual guiding significance to accelerate the sustainable development of NRCMSs in the condition of socialistic market economy.
Methods
1. Method of combination of theory analysis and demonstration research, which included the combination of history retrospection and actuality evaluation, the combination of conclusion analysis and deduction analysis, the combination of macroscopical analysis and microcosmic analysis.
2. Method of references review. This paper retrospected the references about rural cooperative medical systems and researched and analyzed these materials.
3. Method of system economics. This paper used this method to analyze the effect of evolution of system environment on NRCMSs.
4. Method of case study. This dissertation chose the typical case of NRCMSs of Ningxia to analyze and research NRCMSs.
Contents
1. The development course and historical appraisal of traditional rural cooperative medical schemes of China.
2. The development experiences and apocalypse of rural health security systems of other foreign countries.
3. The theoretical viewpoint which are necessary to the research of NRCMSs.
4. The influential factors of fund raising of NRCMSs.
5. The main operation model of NRCMSs of China in the present.
6. The research about the actual situation of operation of NRCMSs.
7. The reformation duties which should be necessary to the sustainable development of NRCMSs.
8. The influential factors of sustainable development of NRCMSs.
Characteristic and Innovative points of research
This research aimed at the sustainable development of NRCMSs which had the great significance in the present society. It had the tight connection with relative policies of rural health development of China. It had its own characteristic in the study field and selection point of view. It had the next innovation points.
1. It used several comprehensive methods to do the systemic analysis and research of theories and cases.
2. This dissertation used the principle of system economics to analyze the effects which the change of system environment had on rural cooperative medical system. From the viewpoints of system project, system confliction, system vacuum, system change, system configuration and system efficiency, it explored the development and evolution of NRCMSs.
3. It thought that we should develop the community mutual and complementary health system and connect NRCMSs with rural health salvation system, and strengthen the connection of health security system between cities and counties, and strengthen the law construction and technology support. In order to ensure the ratio of joining NRCMSs and fund raising level and to reduce the adverse selection, we should implement the principle that all peasants must join NRCMSs.
Main results
1. The development process of Chinese rural cooperative medical schemes included the germination phase (from 1938 to 1955), the form phase (from 1955 to 1966), the development and blossom phase (from 1966 to 1978), the eclipse phase (from 1978 to the end of 1980s) and the recover phase (from 1990 to 2002).
2. The reasons of decline of traditional rural cooperative medical schemes included the affection of structure difference between cities and countries, the environmental change of rural economy and society, the inherent flaw of system itself and the thought confusion at the beginning of reform.
3. It specified the necessity, imminence, hardship and feasibility of the construction of NRCMSs. Our society should cognize this situation roundly.
4. The dissertation analyzed the policy foundation and operation mechanism of NRCMSs and thought that the objective of building NRCMSs should be to prevent peasants from becoming poor because of illness and prevent them from falling into poverty again because of disease.
5. This dissertation thought that we should research NRCMSs from some theoretical viewpoints, for example, theory of community fund raising, theory of system economics, theory of risk management. It also explored the academic evidences of necessity of government interference.
6. The influential factors of fund raising of NRCMSs were composed of health factors, politics factors, economy factors, society factors, culture factors and project of system.
7. The models of NRCMSs were composed of inpatient management pattern, improvement management pattern, cooperative management pattern of individual account and county account, cooperative management pattern of family account and social fund raising, management pattern of insurance company. In these models, inpatient management pattern is the main model.
8. The experimental works showed that there were some differences about attending ratio, compensation ratio, services utilization and funds administration among the north part, middle part and west part of China. Attending ratio of three regions have no the great difference. Compensation ratio is relatively higher in the health institutions with the lower grade. The hospitals of townships are greatly utilized in the middle and west areas of China. But the hospitals of counties are greatly utilized in the east part of China. As for the fund management, the proportion of risk fund of the health finance in the east region is higher than that in the west and middle region.
9. The NRCMSs of Ningxia has obtained the gradual development. The government of Ningxia paid the great attention to this system. Peasants got the more benefits from NRCMSs. But there were still some problems. For example, the higher cost of fund raising, the lower attending ration, the lower cognition of peasants and the lack of restrition and supervision to health institution, which caused the fast increasing of medical fees and was adverse to risk control of funds.
10. The main influential factors of sustainable development of NRCMSs included the next points.
(1) The problem of duty fulfillment of different governments.
(2) The ability and aspiration of payment of peasants.
(3) The manner of voluntary payment and the problem of adverse selection.
(4) The contradiction among illness risk control and moral risk control and justice of raising funds of health service.
(5) There were not only advantages but also disadvantages about the severe illness insurance and outpatient insurance.
(6) The establishment of relative laws was late to NRCMSs .The administration and supervision of insurance system were nonstandard.
(7) How to choose the medical service organizations of NRCMSs.
(8) Faith problem of peasants.
(9) The effect of traditional culture on the behavior of peasants.
(10) The effect of rural oldest-old on the NRCMSs.
(11) The phenomena of fraud and abuse among those peasants who do not take part in NRCMSs.
11. The sustainable development of NRCMSs put forward the new duties and requirements and challenges to matching reform of rural health work of new time. We should connect NRCMSs with rural health salvation system, and strengthen the connection of health security system between cities and counties, and strengthen the law construction and technology support.
Suggestions
1. Confirming the duty of government.
2. Implementation of compulsion principle of attending NRCMSs and decreasing the phenomena of adverse selection.
3. Accelerating the process of formulating laws of NRCMSs.
4. Building the rational mechanism of raising funds and compensation.
5. Developing the mutual and complementary health of community and advocating the attempt and multiplicity of system model.
6. Enlarging propaganda and strengthening the faith of peasants.
7. Boosting the associated reforming of medical treatment, health insurance, curative and public health.
8. Controlling the phenomena of fraud and abuse effectively.
9. Strenghtening the information and network construction of NRCMSs.
10. Implementation of rural health salvation system in the poor areas.
11. Developing the rural economy greatly.
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