会员登录
会员注册Abstract
Market-oriented reforms in the health sector together with fiscal decentralization have led to low efficiency of resource allocation and utilization, increasing inequality as well as reducing the ability of the poor to access health care services in China. This situation creates greater health vulnerability for those who are initially at greater risk of disease but who are not under the cover of social protection. For the purpose of providing the rural poor basic health security, it is necessary to implement targeted programs to provide preventive services, to invest in village-level health care services that the poor most frequently need, to strengthen the resources available to the poor and the aged with health relief, and to link the community-based health insurance programs with formal insurance services.
Key Words: health security, rural poor, China
During the two decades since the end of 1970s, China’s market-oriented economic reform has exerted a robust effect in improving the overall efficiency of a national economy as manifested in rapid economic growth. This achievement is also seen in an apparent income increase of the entire Chinese population and a dramatic reduction in poverty. However, the marketization process has also engendered a widening rural-urban gap, increasing regional disparities and income inequalities that have become an important cause of the newly poor. Moreover, it has placed individuals and households under greater risks and uncertainties that cannot be mitigated by existing informal protection systems. The process of restructuring a social protection system adapted to the socioeconomic transition lags behind the pace of marketization. Except for the top-level income group, those outside of formal security systems have become more vulnerable than they had been prior to the transition.
The growing health vulnerability of the rural population is clearly seen in the recent SARS outbreak. Although a booming medical market emerged during the transition, medical services and drug markets remain far from being well-regulated, corruption in the process of drug procurement has become rampant: this precipitated price hikes and led to the decline of health service accessibility. It now frequently happens that the low-income segment of the rural population cannot afford medical treatment: their minor illnesses often turn into much worse health problems. It is even not rare for the upper-middle income rural families to fall into poverty due to catastrophic illness. The vicious circle between poverty and illness has become an issue that has drawn wide public concern and calls for prompt policy intervention.
This paper will mainly deal with the health insecurity problems that rural Chinese residents have been facing during the current socioeconomic transition. Firstly, an introduction to system changes in basic health care and health financing will be given, and the socioeconomic impact of the transition will be reviewed with macro-level information. Secondly, the paper will determine the vulnerable health groups through household livelihood analyses, and through data concerning the use of medical service by a sample of the population in such a way that the residual insecurity under the existing health risk-pooling systems will be identified. Thirdly, necessary policy intervention with reference to India’s experiences will be discussed.
I. Impact of Changes in Health Care Financing
As early as in the mid-1960s, a three-tier health service network (county, township, and village) was formed in rural China, which was in charge of both rural medical treatment and health care. In the highly centralized planning system, via this network, public health programs sponsored by the government could be implemented rather smoothly in the countryside. Rural health workers widely known as “bare-foot doctors” played major roles in providing easy and quick access to primary health care for the rural population. These rural health workers received their remuneration from their respective production teams in the form of work points, whereas villagers paid cash for drugs that were characterized by their low cost. The so-called cooperative health care system, which was operating in most areas in China at this time, was the grassroots public health service system closely associated with the functioning of the Commune system (Zhu, 2002a). Furthermore, the government retained firm control over medicine production and sales, so as to guarantee a reliable and inexpensive supply. These institutional factors along with strong government financial support for public health contributed decisively to the improvement of the rural population’s health despite the overall low level of services.
Since the early 1980s, the rural health care system has undergone far-reaching marketization reforms in tandem with China’s overall economic system. The major motive for market-oriented reforms in the health care sector lies in the government’s attempt to use market function to deal with the problem of public health financing and control of health care costs. While pursuing financial decentralization, governments at a higher level have often delegated the responsibility of health care financing to the governments at a lower level, but the latter, however, are often in financial difficulties that result in the transfer of the responsibility further down to health care institutions. When this happens, the problem is now being settled as the market determines. Such a policy orientation became visible as early as 1985 when the government announced the health care reform program.[2] This policy document neither tried to design a mechanism to encourage government authorities at various levels to increase investment in public health, nor did it find a way to rein in medical costs. Instead, it allowed medical institutions to set their own fees so as to deal with the shortfall in government financing.
As a result of financial decentralization, the three-tier health service network in rural China has been challenged by the decline of public investment. One of the manifestations is the notable decline of the share of public health expenditure in the total financial expenditure.[3] The share of public health expenditure declined from 2.49% in 1980 to 1.71% in 2000. The cooperative health care system virtually disappeared following the collapse of the People’s Commune System, and the overwhelming majority of village health clinics were privatized. Subsidies for public health services at and above township levels were reduced, [4] and rural health service became increasingly profit-oriented. As medical services and drug markets remain far from well regulated, corruption in the process of drug procurement has become rampant. It has been no more secret that hospitals and drug stores receive considerable amount of sales commission from medicine producers while they also obtain a large price margin by selling drug to patients with price hike. Compared with 1995, the cost of hospitalized treatment for appendicitis in 2000 increased by 37.2%, the cost of hospitalized treatment for pneumonia increased by 83.2%, whereas during the same period the net per capita income of rural households increased only by 25.9% (Diagram 1).
The above-stated changes resulted in a backwards-turning point from the pre-reform policy that had effectively combined basic biomedical intervention and public health care (Wilson, 1992). In order to reverse such a trend, the Chinese government has been making efforts to re-establish the cooperative health care system, as well as to carry out experimentation with various forms of health risk sharing system in regions at different development levels, while making investments in upgrading public health care facilities and addressing the problems in the health care and drug market. However, the over-all trend has not yet been reversed, as the strength of the intervention is far from sufficient.
The impact of changes in health care financing on the rural population are not directly manifested by the overall health outcome as the health outcome is determined also by other factors, such as nutrition, clothing, housing, jobs, education, living environment, behavior, lifestyle, etc., (Fuchs, 2000). Nevertheless, the impacts may be observed in the following:
1. Increasing medical costs borne mainly by patients. In the 1980s, total health expenditure in China was 3% of GDP. In the early 1990s, the ratio increased to 4.1%，and in 1999 it reached 5.1%The Editorial Committee of Health Yearbook, 2001）. The increase in health care expenditure during these years was mainly borne directly by patients (Diagram 2).
2. Declining utilization of health care resources. A report by the Ministry of Public Health pointed out that “compared with 1990, in 1998 the average patient-seen- per- doctor fell from 1,683 to 1,178; the utilization of hospital beds declined from 80% to 60%,” and that “insufficient health resources co-exist with their waste ….” (Cf. Ministry of Public Health, 1999: pp.188, 190).
3. Widening rural-urban gap in health resource allocation. The urban population, especially the unemployed and their families, has also suffered from the marketization of health services, but investment in health care by both central and local governments has been concentrated in the cities. Social medical insurance and social aid system have also been mostly developed in the cities. This being the case, health care services are biased against the rural population. By the end of the 1990s, the rural population accounted for more than 70% of China’s total population, but rural health care expenditure accounted for only about 20% of the total government expenditure on health care. [5]
4. The notable reduction of access to medical services for rural people. According to the State Health Service survey organized by the Ministry of Public Health, in 1993, of those rural patients who should have been hospitalized but were actually not, 58.8% was not because of economic difficulties. In 1998, this ratio increased to 65.3% (cf. Ministry of Public Health, 1999).
5. Aggravation of the vicious circle between poverty and illness. According to recent calculations, poor households[6] accounted for 7.2% of the total rural households in 1998, whereas the non-poor households falling into the category of poor households due to medical expenses accounted for 3.3% of the total households. This means that, from the point of view of family consumption expenditure, the poverty rate went up to 10.5% (Liu, Rao, and Hu, 2001).
6. Jeopardizing preventive health service provision, which relies on public budget and reducing particularly preventive activities at grassroots level. To be sure, the government did not give up its management role in public health[7], nor has it forgotten to insist that village clinics should continue to take the responsibility of epidemic prevention, maternity and childcare, and family planning. In the government document of health care reform announced in 1985, one item stipulated that any institutions or individuals were allowed to run village clinics, but the village should provide appropriate subsidies for the labor input by rural doctors/health workers in public health work. In the poor areas, local governments were also required to provide assistance and subsidies for such activities (The State Council, 1985). These requirements, however, were difficult to meet in other than economically more developed areas. As a result, in most rural regions, especially the poor regions, preventive services either remain poor in terms of service supply, or have began to charge fees. This doubtlessly adds more constraints on the poor to obtain preventive services and creates greater health vulnerability for them.
II. Identifying Rural Health Insecurity
No one knows when and how serious sicknesses may occur (Arrow, 1963), but it is established that those in poor living conditions and those experiencing certain biologic functions, the pregnant for instance, or those within certain moments of the life circle such as the infant and the aged are at greater health risk. However, even the high-risk groups at low-income level are not unavoidably vulnerable when they are protected by social security systems or when they are supported with other forms of safety nets.[8] The health care services with public support that bring about easier accessibility can also alleviate insecurity of the high risk-groups. Based on this understanding, this section presents an overview of the social security[9] coverage in China using recent national statistics. The vulnerable health groups are identified mainly through individual and household level information.
The institutions that more or less protect the rural population from illness or deal with illness- related income and expenditure shocks in present China are listed below:
1. Formal health insurance systems:
· Commercial health insurance;
· Social health insurance programs;
· Community-based cooperative medical insurance schemes (effectively functioning only in few well-off counties);
2. Health relief and assistance:
· Medical relief to the major income earners falling seriously ill (cases from the rural health project financed by the World Bank for a few poor counties in southern Shaanxi Province);
· Social assistance with cash transfer to the aged confronting catastrophic illness or injuries (cases from the townships in Shaoxing, Zhejiang Province);
· Assistance to women living in poor households with subsidized maternal services (cases from the rural health project financed by the Chinese Poverty Alleviation Foundation for Lijiang County, Yunnan Province);
3. Selective health service provision with budgetary subsidies:
· Rural health education schemes (seriously lacking funds and organization);
· Targeted preventive health plans:
- Prenatal and maternal care programs;
- Immunization programs for children under age 7.
4. Informal risk pooling among family members, relatives, friends and neighbors.
Although it seems that there is well-established social protection system to provide the rural population with health security measures, the coverage of the formal security schemes is extremely limited. Health relief and assistance have functioned only in few developed regions and in those poor areas where health promotion projects were carried out with poverty reduction funds during the project period. The budgetary subsidies allocated to rural health education and targeted preventive health plans are not sufficient to support the full-time operation of the programs. For example, the immunization program was designed to be free of charge for children under age 7. The central government provided funds for vaccines while leaving the payment for service to local governments. However, the majority of the local governments have not paid the cost due either to unwillingness or inaffordability. Parents must pay at least 1 to 3 yuan for one injection of the vaccine with the result that certain of the rural poor gave up participating fully in the program. Due to the financial and geographical difficulties regarding access to reproductive health care, around 40 per cent of the pregnant women from poor rural households did not receive prenatal care from health workers. A similar proportion of the rural pregnant in poor areas did not give birth to a child at a health center or in a hospital (Gao, 2003).
With regard to health insurance programs, those covered by all types of health insurance schemes in China accounted for only 27% of the total population in 1998, and the coverage rate was 55.9% and 12.7% respectively for urban and rural population.[10] As the aging and aged belong to high health-risk groups while their earning ability is declining, pension scheme coverage has then significantly determined their capability to cope with growing medical expenditures (Li, 2003). Pension scheme coverage is estimated at 29.5% for urban residents and 7.5% for rural residents respectively in 2001 (State Statistics Bureau, 2003). Apparently, there is a considerable proportion of the population not covered by the two most important schemes, while the uncovered rural portion is substantially larger than the urban (Diagram 3 and 4). Due to the fact that the average rural income is lower than urban income and poverty in most parts of the countryside is more severe than in urban areas, it is obvious that the rural population is more vulnerable when facing health threats.
The insurance schemes covering urban residents are essentially related to their work in a formal economy, just as can be found in any developing country. The rural resident covered under the two formal systems mainly consist of employees working in rural industrial and service enterprises. Farmers and their family members account for the major part of the uncovered. They are secure only in their entitlement to land tenure.
Thanks to the great improvement in land productivity, most farmers’ households have achieved food security with a very limited acreage, on national average only 0.6 hectare per household (State Statistics Bureau, 2002). However, the shortfall in the basic needs met by the income generated from land-related activities is growing because of the marketization process (Fan, 2003). This is particularly the case for health care and education needs that have become increasingly expensive given the government shifting of financing responsibilities onto individuals. Those living on land with poor soil and low productivity are not able to obtain food security. That is why the first priority of the rural poverty reduction programs has been given to solving shortages in food and clothing for the poor.
In order to overcome the problem of insufficient investment in public health and the very limited coverage of the health insurance systems, a number of counties/cities in the eastern rural regions took the lead in re-establishing public village clinics, integrating township and village medical prevention services, and creating community-based cooperative medical insurance schemes or social health insurance systems. In other regions especially in the poorer regions, similar efforts rarely produced successful results（Zhu , 2002a）. The majority of the rural population has to rely on informal securities to protect themselves against health-related risks. Nevertheless, it is widely understood that informal security, such as mutual assistance via family ties, friends, neighbors, and rotating saving groups, etc., are unlikely to have the capacity to protect the rural population from ever greater risks and the uncertainties emerging in the process of marketization, industrialization and urbanization (Platteau, 1991).
The characteristics of rural health insecurity can be more precisely presented through descriptive statistics derived from the author’s sample survey.[11]. In a total of 1,989 sample households (7900 people) those reported to have been covered by cooperative medical programs accounted for 11.8 % (see Table 1). Moreover, the school children aged 8-16 (nearly 13% of the sample population) are insured against accidents and hospitalization. These two categories may have some overlap in terms of the participation by the sample population and the benefit packages of the two are very different. These results, however, still support the previous statement that the rural majority is health insecure. Clearly, among the insecure those with greater health risks are more vulnerable.
According to the self-reported incidence of sickness in two weeks prior to the survey, Diagrams 5-8 show the sickness incidence occurring with the sample population and the choices that the patients made for dealing with the illnesses. Our statistics shows that those reporting being ill constituted about 10% of the total sample. The sickness incidence of females reported was 12.6%, 3 points higher in the percentage than the sickness incidence of males. Those over age 64 constituted 27.6% of those reporting illnesses. In the group of pre-school children under age 7 the proportion of the ill accounted for 13.3%. The lowest figure -- 5.2% --was that of the group of school children between ages 8-16. It must be pointed out again that only this age group is covered by commercial insurance, due to the business campaign launched by insurance companies throughout the schools. The companies ruled out the group over age 60 and required much higher premiums for other age groups, with the result that the majority of farmers gave up buying commercial insurance.
Diagrams 5 and 6 show even more clearly that the poor[12] suffered from a higher incidence of sickness than others (14.4 and 10.1%). About 70% of those falling ill that visited doctors chose medical treatment from the village clinics, which generally receive nothing from government budgets. There were also a remarkable number of patients from both the poor and the non-poor groups that bought medicine on their own for self-treatment. This practice apparently helps to reduce the cost of medical treatment, but it contains health risks that cannot be ignored. To buy and take medicines without a doctor’s examination and prescription may well result in the indiscriminate use or misuse of medicines. This is even more risky for those who do not have much health knowledge. This concern can be supported by the fact that the heads of poor households who reported to have received health education services in our sample accounted for less than 30% of his/her income group while the share of the non-poor was within the range of 35-41%.
The above information tells that the poor, the aged, females, and pre-school children are at greater risk against diseases in comparison with other age/gender/income groups. The medical services that the rural residents most frequently use are provided by the village clinics.
3. Residual health insecurity Residual health insecurity can be generally defined as that situation arising when an individual or a group of individuals are outside health security institution coverage. . To formulate well-targeted policy intervention, it is crucial to identify the residual insecurities. Due to the differences in security institutions between countries and regions, residual insecurity must be identified in a country- specific and region-specific manner. Examining the present institution coverage in rural China, the groups living in residual health insecurity may be identified as follows:
1. Those excluded by social health insurance schemes or/and by commercial insurance programs;
2. Within the above groups those outside community-based cooperative health insurance programs and those who are inside but whose medical expenses enormously exceed the limits of the benefit packages offered by the cooperatives;
3. Those who are eligible to receive subsidized provision of selected health care services whereas they have not been reached yet by the services, or those with limited access to the targeted health programs;
4. Among those who are neither covered by any of insurance programs nor by targeted health plans, the poor, the aged and the major income earners suffering from serious sickness but failing to obtain relief or assistance.
As Diagram 9 shows, the above categories can be ranked by severity of the insecurity. With regard to the ranking, a point must be made about the rural migrants working in urban areas without health protection provided by the urban security institutions. Though they live economically better in the urban area than in their home villages, most of them have to face greater health risks and more expensive medical services in cities and towns. Due to the institutional barriers against rural-urban migration, migrants actually are f the major income earners for their rural families while they belong to the most vulnerable group in urban society. Moreover, among the rural residents falling in the above categories, those who are weaker in controlling household assets or in maintaining social relationships with family, kinship and community, and those who lack an income-generating capacity are considered to live in residual health insecurity in relationship to the informal institutions. Furthermore, in the insecure groups those who are most disadvantaged in intra-household resource distribution are the most vulnerable. Because of the limitations resulting from a snapshot survey, our data set can neither describe the informal risk-pooling arrangements between the sample households, nor does it contain information about intra-household resource distribution among the individuals. Nevertheless, our data can be used to describe the economic characteristics of the health vulnerable groups through household livelihood analyses.
Table 1 to 3 present comparisons between the poor and non-poor sample households in assets possession as well as in composition of total expenditure and consumption expenditures. Apparently, the non-poor households have fewer members but they enjoy a greater labor ratio. The heads of the non-poor households received higher formal education than those of the poor households. This implies that the non-poor households are able to deploy a stronger labor force in income generating activities. Although the non-poor households possess smaller sizes of cultivated land than the poor, they possessed much larger amounts of financial and physical capital that partly reflects more dynamic non-farming activities. Given that all the households in a village enjoy only the usufruct right of land stipulated by law as unmarketable, the possession of financial and physical capital reveals substantial differences between the households in wealth. The production and non-production assets value of the poor amounts to 11,644 yuan, the equivalent to nearly 40% of the assets value of a sample household on average（Table 1）. It is understood that household assets can be used to cope with economic risks. However, the assets of the majority of the sample households are far from sufficient to deal with income shocks resulting from catastrophic illnesses. This is particularly the case for the poor. For instance, the hospitalization fee in rural areas for cancer cost a patient 5,092 yuan at a national average in 1998, and the amount would be doubled if one were hospitalized in urban hospitals[13]. This sum is respectively equivalent to a half and a total of the assets value of the poor in our sample.
The health vulnerability problems of the poor can be further identified with the following features of the subsistence economy that the poor largely live in:
l In terms of the total expenditure of the households on average, consumption assumed a considerably larger weight than production. The former shared 50% of the total expenditure while the latter made up 41% . The proportion of consumption in the total expenditure of the poor households was even larger than that of the average, though the poor spent noticeably less on consumption in absolute value, accounting for only about 45% of the average (Table 2).
l The poor households were under very hard budget constraints for meeting their non-food basic needs, as their food expenditure already accounted for 56% of total consumption (Table 3). It appears that the shares of health and education in the total consumption of the poor did not differ significantly from those of the non-poor, but the non-poor actually spent as much as 2.4 and 2.9 times respectively of what the poor did on health and education.
In terms of health resource distribution within a poor household, the interviewees in our sample noted that given the hard budgets constraints the household members were generally ranked as follows: major income earners, children, and then the aged. At each ranking level the male usually took priority over the female due to traditional gender inequality. Frequently it was the case in extended families that the aged over 60 years would prefer to give up medical treatment for catastrophic illness in favor of spending money for the health care of their children and grandchildren. During the current socioeconomic transition, the majority of extended families are separated into nuclear families, which has led to a rapid increase in the number of “vacant nest families” with only an old couple or a single aged person living alone. In our sample, there were 75 “vacant nest families” with their household head over age 60 ( 3.8% of the total sample households) and one-third of this type of families were poor. Since most rural residents were not covered by pension schemes, the livelihood of the aged in poor households became noticeably insecure. The aging couples without working capacity were supported by their children with food and the usual necessities, while the children cultivated the land plots of the aged parents. For those aged without children, the villager committees took care of them in the same way. However, constrained by the lack of cash income, the aging in poor areas often confronted difficulties in obtaining medical treatment when ill.
The above information indicates that all of those rural residents without a formal security cover tend to become more vulnerable as the result of deteriorating accessibility to the preventive and curative medical services because of the changes in health care financing. Among them, the poor, the aged, females and pre-school children are at more risk from diseases. However, the aged living in poor households formed the most vulnerable group owing to deficiencies in both public and family support in caring for their health.
III. Options for Policy Intervention
The discussions carried out in this paper point up the fact that marketization in the health sector without sufficient government intervention[14] is unable to overcome the difficulties of financing and cost control. The market-oriented transition has led to low efficiency in resource allocation and utilization, increasing inequality as well as reducing the capability of the poor to access health care services. It has then created greater health vulnerability for those who are initially at greater disease risk but who are not covered by social protection. These problems were clearly revealed during the period of the SARS outbreak that gave an impetus to the government and the public to attempt to rein in the extreme marketization tendency in the health sector.
However, it will be noticed that government intervention prior to the SARS outbreak (for example, the experiments with rural health insurance programs) has achieved limited success in the well-developed regions although it has yet been far from effective in the middle- and less-developed regions. It has been established that social medical insurance and cooperative health care systems sustainability in the more developed regions not only depends on the relatively high rural average income, the strong willingness of farmers to avoid health risks, efficient provision of health care services, and reliable management of insurance funds, but also depends on social mobilization with government involvement and financial support as important preconditions (Wei, 2003). Unfortunately, most of these conditions are lacking in large parts of rural China.
Moreover, the ongoing health plans are designed mainly to promote reproductive health care. There are neither preventive schemes to protect rural working-age groups— especially the group of rural migrants working in the urban areas—from the major killer diseases, nor specific programs to care for the aged, especially aged women, to help them resist t frequently-occurring illnesses. Therefore, it is necessary for the Chinese government to carefully re-identify the health vulnerability that different income/gender/age/regional groups have encountered and improve further the public health policies with specific consideration favoring the health vulnerable groups.
Based on the understanding stated above, it is suggested that a rural health protection system shall be restructured in a stepwise way for meeting the basic health security needs of the rural population. The coverage of basic health security depends not on health demands, nor on the supply of health resources, but on political decisions made by members of the entire society.[15] In other words, the health risks that members of a society commonly agree to share during a specific period of time, and the health care services that are deemed to be accessible to everyone regardless of affordability, constitute the coverage of basic health security. To achieve basic health security for the entire rural population, joint efforts must be made with participation of the government at different levels, village communities, households, and NGOs.
The first priority in restructuring the basic health protection system is to improve and extend the rural immunization programs. It is feasible for the central government to render additional funds to preventive institutions according to the services that they provide to children through their planed immunization programs such that the programs can be implemented thoroughly free of charge. In regard to this point, China should learn from the experience of India where child immunization services have been provided free of charge for many years.[16] Compared with China, India is a country with a similar huge population at similar developmental level. This implies that whether the Chinese government undertakes the necessary costs of child immunization services depends less on its fiscal ability than on its political will.
It is then further suggested that the coverage of working-age adults in immunization programs be extended specifically to protect them from the most frequently occurring infectious diseases, such ashepatitis. Currently in China there are 2 million patients suffering from viral hepatitis and more than 100 million hepatitis-positive. It is deemed crucial for the successful implementation of such programs that both the central and local governments be ready to subsidize the rural working adults and the migrant workers in the urban sector in particular. To avoid leakage of project resources, the subsidies can be delivered by using coupons valid only for the targeted groups and this distribution can be well organized through villagers committees, urban residents committees and the migrants’ work units. The immunization service providers will be eligible for re-imbursement from the government upon delivery of the coupons.
The health care services that the rural residents, especially the poor, have most frequently used are provided by private doctors or health institutions at village level （Gertler and Hammer, 1997；Filmer，Hammer and Pritchett, 1997；Zhu, 2002b）. Hence, the welfare of the rural health vulnerable groups will be substantially improved if the government prioritizes its financial support to village clinics. It was observed that the Indian government has already implemented such reasonable policies (for example, the health workers in village clinics were paid salaries by the Gujarat State government. In this regard, one feasible step for China is to adapt the Indian practice to local conditions, thereby providing strong incentives for village health workers to improve their service quality.
Firstly, the health workers should be paid an amount sufficient to engender incentives for them to provide villagers with the best possible health education and disease prevention services.
Secondly, the pre-reform tradition that budgetary resources were used to finance periodic training courses for village health workers should be restored. This is because most training courses are currently organized through trainees’ payment at such a level that the demand of the village health workers for the training is in decline in poor areas.
Thirdly, using the framework of community-based cooperative medical systems, an incentive structure should be designed to stimulate village health workers to offer villagers inexpensive and reliable medical services. In addition to the remuneration system for the health workers (i.e. basic salary plus registration fee that is practiced in the village clinics in well-developed regions), a system of medical cost transparency and supervision by a public health regulatory institution at township level should be added.
In most cases social relief is delivered to the rural poor to cope with income shocks after the misfortune has occurred. Nevertheless, the poor badly need assistance during the course of the event (such as a serious illness). This problem could be relieved through publicly financed medical coupons with which the poor will be able to visit doctors or be hospitalized. This system of relief in medical coupons has been practiced in Shanghai since the beginning of the state-owned enterprises reforms and to a large extent it has enabled unemployed workers to purchase basic health care services. There would appear to be mo major operational difficulties for local governments in rural counties to adopt a similar system for helping the poor, even though the fiscal capacity of rural counties is considerably smaller than that of Shanghai and even though the resources available for the delivery of medical relief are much more limited.
Subsidies to the poor for paying cooperative health insurance programs premiums are deemed another form of health relief. Without such subsidies either the poor households will be excluded from the insurance programs or the programs cannot work from the very beginning in the villages and areas where the poor and the less poor constitute a large proportion of the total households.
Social assistance and relief programs targeting the rural aged must be addressed since there is a long way to go before formal pension schemes are established for the rural population. However, it should be a logical policy option to set up a pension scheme starting with the health component. That is to say, one could encourage rural residents to save during their working age in an accumulated pension fund that can be later dispersed to meet their basic health care needs when they reach retirement age. One would thus anticipate that the health pension program could be operated as a supplement to family and community care after the basic needs of the aged for food, clothing, shelter, etc., have been met. This type of institutional design can be observed in the welfare funds in Kerala, India where the labor unions in different informal sectors collect a small amount of the savings from the member workers: those contributing are eligible to receive a certain amount from the specific fund for covering their specific needs.[17]
China’s current community-based cooperative health insurance system faces two kinds of difficulties: one lies in the fact that the risk pool is so small that it is incapable of sharing catastrophic disease risks without running deficits. The second involves high management costs. Certain of India’s production cooperatives and NGOs have instituted innovations that may serve to enlighten us about how to overcome these difficulties: essentially, they link informal insurance programs to formal ones. The experience of the Malabar Regional Cooperative Milk Producers Union may serve as a good example.
The Union implemented its Mediclaim Insurance program with the Oriental and New India Assurance Companies. The member farmers of the Union fully paid the premiums of Rs.130 per annum[18]and they were entitled to receive the hospitalization treatment benefits up to Rs.15,000 per year. The Union acts as a facilitator to organize the member farmers together to reach a contract with the commercial insurance company. In this way, both contractors were benefited from the organizational advantages of each side. By such a group insurance arrangement the commercial insurance company enlarged its pool of participants. The individual farmers obtained access to the formal insurance program that the commercial insurance companies usually refuse to offer them due to high transaction costs of engaging in small business with individual farmers.
In 2003, a new type of rural health insurance program designed to cope with risks of catastrophic illness was launched with central government financial support thought a transfer of 10 yuan per rural resident per year in China. Clearly, the villagers’ committees and township governments that have taken the leadership in the implementation of the program could learn from the Malabar Regional Cooperative Milk Producers Union in order to create a similar linkage between cooperative health insurance and commercial services.
At present, all of the ongoing insurance plans are operated locally; they are, therefore, far from adequate to promote and protect that labor mobility required by industrialization and urbanization. A basic health insurance program with universal coverage is certainly a correct solution. Yet, for an enormous country like China with its 1.3 billion citizens to establish a sustainable universal social health insurance system will no doubt require tremendous efforts in terms of social mobilization and organizational work. It may indeed be advisable to begin with establishing social health insurance against specific diseases, whose diagnosis and treatment are more easily standardized. Infectious diseases, especially acute infectious diseases，have just such characteristics as opposed to noninfectious chronic diseases.[19] Moreover, infectious diseases most frequently threaten both rural residents and rural migrants working in urban sectors. To establish a universal health insurance program against infectious diseases will no doubt increase the ability of these health vulnerable groups to protect themselves through the given financial arrangements.
To universalize a designed health insurance program, participation must be compulsory. Furthermore, making compulsory health insurance a part of the social protection system will warn in terms] both government and individuals to prepare for sharing health risks, and at the same time clarify the responsibility between them. To build a universal social health insurance beginning with preventing infectious diseases will contribute not only to public health security and economic security, but also to the promotion of nationwide labor mobility, leading to the narrowing of urban-rural and regional disparities. This would serve as a crucial step in social policies integrating a society currently divided into cities and countryside. As social wealth and personal incomes grow, government and social administrative ability must advance, and as the insurance awareness of citizens increases, universal social health insurance must move forward from covering infectious diseases to covering also noninfectious chronic diseases (e.g. cardiovascular diseases, cancer, etc.). When that day comes, China will be able to achieve simultaneously economic and social integration by eliminating the existing dual economy and dual society. This is where the long-term social and economic significance of the establishment of social health insurance against infectious diseases lies.
Arrow, K .J., 1963:”Uncertainy and the Welfare Economics of Medical Care”, 1963, vol.53, pp.941-967. American Economy Review,
Fan Hua, 2003, Farmers’ Ability of Payment and Willingness to Pay the Rural Health Cooperative Insurance, Ch.2-3, dissertation at the Institute of Economics, CASS, Beijing.
Filmer, Deon , Jeffrey Hammer and Lant Pritchett，1997, Health Policy in Poor Countries: Weak Links in the Chain, www.worldbank.org/wbi/publicfinance/publicresources/filmer98.pdf
Fuchs, Victor R. 2000, （Chinese Edition）shui jiang shengcun? Jiankang, jingjixue he shhui xuanze (Who Shall Live? Health, Economics, and Social Choice), translated by Luo Han, Jiao Yan and Zhu Xueqin, Shanghai: Shanghai remin chubanshe (Shanghai People’s Press), pp.82-86, and 94-95
Gao Mengtao, 2003, Reproductive Health of the Rural Women in Poor Areas, Ch.3, dissertation at the Institute of Economics, CASS, Beijing.
Gertler, Paul, and Jeffrey Hammer, 1997, Strategies for Pricing Publicly Provided Health Services, www.worldbank.org
Health Statistics and Information Center of Ministry of Public Health of P.R.China, 2002，National Health Expenditures at Various Periods (Quanguo gege shiqi weisheng shiyefei), in China Health Statistics Abstract 2002 (2002 nian zhongguo weisheng tongji tiyao), Beijing www.moh.gov.cn/statistics/digest01
Li Enping, 2003, Effects of Economic Status of the Rural Aging People on Their Utilization of Medical Services,” Ch.4-5, dissertation at the Institute of Economics, CASS, Beijing.
Liu Yuanli, Rao Keqin and Hu Shanlian, 2001, “The Necessity to Establish the Rural Health Protection System in China and Relevant Policies” (Lun jianli zhongguo nongcun jiankang baozhang zhidu zhi biyaoxing he xiangguan de zhengce wenti), (Research Report), pp.7-9, presented at the International Symposium “Rural Basic Safety Nets in China”, July 9-10. Beijing
Ministry of Labor of P. R. China, 2002, Issue of Statistics on Development of Social Security in 2001 (2001niandu laodong he shehuibaozhangshiye fazhan tongji gongbao), Beijing.
Ministry of Public Health of P.R.China, 1999, Research of the State Health Services –Analytical Report of the Second State Health Service Survey 1998( Guojia weicheng fuwu yanjiu --1998nian di’erci guojia weisheng fuwu diaocha fenxi baogao), (unpublished research report) pp. 181-192, Beijing.
Ministry of Public Health of P.R.China, Management Bureau of the State Chinese Medicine, 2002, Collection of Frequently Used Health Regulations and Rules (Changyong weisheng fagui huibian), Beijing: Law Press (Falu chubanshe)
Platteau, Jean-Philippe, 1991, “Traditional Systems of Social Security and Hunger Insurance”, in Ehtisham, Ahmad, Jean Dreze, John Hills and Amartya Sen, Social Security in Developing Countries, Oxford: Clarendon Press for Wider, pp.112-170.
Sen, A. 1981, , Oxford: Clarendon Press, Ch.1-3, pp.6-38. Poverty and Famines
State Council, 1985，The State Council Notice on the Report by the Ministry of Public Health on Reform Policies concerning Health Work (Gguowuyuan pizhuan weishengbu guanyu weisheng gongzuo gaige ruogan zhengce wenti de baogao de tongzhi), April 25, www. jkcj.yeah.net。
State Statistics Bureau, Statistical Yearbook of China (Zhongguo tongji nianjian), 1999 and 2002, Beijing: Statistics Publishing House of China (Zhongguo tongji chubanshe).
Wei Zhong, 2003, Analyses on Rural Health Insurance System in Jiangyin City, discussion paper at the Institute of Economics, CASS, Beijing.
The Editorial Committee of Health Yearbook (Weisheng nianjian bianweihui) 1999, China Yearbook of Health (Zhongguo weisheng nianjian). Beijing: People’s Health Press (Renmin weisheng chubanshe), pp. 168-169, 396 and 410.
Wilson, Gordon, 1992, “Diseases of poverty”. In T. Allen, A. Thomas (eds.) Poverty and Development in the 1990s, Open University Press, p.34-54.
Zhu Ling，2002a，Farmer Preferences in Choosing Health Programs with Insurance Components, World Economy & China, No.1, Beijing.
Zhu Ling, 2002b，The Usage and Management of Village Health Service (Cunji yiliao fuwu de liyong he zhili), forthcoming, Beijing
 |
 |
Source for Diagram1-2: Health Statistics and Information Center of Ministry of Public Health of P.R.China, 2002，National Health Expenditures at Various Periods (Quanguo gege shiqi weisheng shiyefei), in China Health Statistics Abstract 2002 (2002 nian zhongguo weisheng tongji tiyao), Beijing www.moh.gov.cn/statistics/digest01
Source: Ministry of Public Health , 1999, Analytical Report of the Second State Health Service Survey 1998, (unpublished Chinese version), pp. 181-192, Beijing.
Source:Ministry of Labor and Social Security, 2001, Statistical Bulletin on Development in Labor and Social Security in 2001, Beijing. www.molss.gov.cn/tongji/gb/GB2001.htm
Diagram 5. Types of Health Service Providers Chosen by the Non-poor[20]
 |
Diagram 6. Types of Health Service Providers Chosen by the Poor
 |
Diagram 7. Reasons for Not Visiting Doctors by Gender Groups
 |
Diagram 8. Types of Health Service Providers Chosen by Age & Gender Groups
 |
Diagram 9. Rural Health Vulnerable Groups by Severity of the Insecurity
 |
Table 1. Comparison between the Poor* and the Non-poor in Mean Household Assets Possession in 1999
Note: * In this table and the following the poor refers to the low income group with annual per capita net income below 1000 yuan, while the non-poor refers to those at the income level above 1000 yuan. Here the middle income refers to the level of 1000-2000 yuan.
**Figures in bracket are standard deviation; *** 15mu = 1 ha
**** Referring to the area that a household received from the process of land distribution in its village community.
Table 2. Comparison between the Poor and the Non-poor in Composition of Household Expenditures
| Per capita Net Annual Income | Statistics | Total Annual Expenditure | Production | Consumption | Others |
| Below 1000 yuan | Mean (yuan) | 7190.39 | 2774.91 | 3718.91 | 695.96 |
| | Percentage | 100 | 39 | 52 | 10 |
| | STD | 12753.2 | 11464.14 | 3216.2 | 1140.89 |
| | Number of HH | 266 | 266 | 266 | 266 |
| Above 1000 yuan | Mean (yuan) | 17952.05 | 7405.97 | 9050.43 | 1495.354 |
| | Percentage | 100 | 41 | 50 | 8 |
| | STD | 37586.95 | 30301.91 | 14048.98 | 5057.60 |
| | Number of HH | 1723 | 1723 | 1723 | 1723 |
| Total sample | Mean (yuan) | 16512.83 | 6786.64 | 8337.42 | 1388.45 |
| | Percentage | 100 | 41 | 50 | 8 |
| | STD | 35480.26 | 28554.38 | 13252.85 | 4733.32 |
| | Number of HH | 1989 | 1989 | 1989 | 1989 |
Table 3. Comparison between the Poor and the Non-poor in Household Consumption Expenditures
| Per capita Net Annual Income | Statistics | Total annual Consumption Expenditures | Food | Health | Education | Others |
| Below 1000 yuan | Mean (yuan) | 3718.91 | 2093.75 | 178.4 | 238.93 | 1207.83 |
| | Percentage | 100 | 56 | 5 | 6 | 32 |
| | STD | 3216.2 | 1220.29 | 451.21 | 607.69 | 2453.19 |
| | Number of HH | 266 | 266 | 266 | 266 | 266 |
| Above 1000 yuan | Mean (yuan) | 9050.43 | 3909.74 | 432.08 | 692.07 | 4016.54 |
| | Percentage | 100 | 43 | 5 | 8 | 44 |
| | STD | 14048.98 | 3223.01 | 1785.57 | 1488.9 | 12264.33 |
| | Number of HH | 1723 | 1723 | 1723 | 1723 | 1723 |
| Total sample | Mean (yuan) | 8337.42 | 3666.88 | 398.15 | 631.47 | 3640.92 |
| | Percentage | 100 | 44 | 4.7 | 7.6 | 43.7 |
| | STD | 13252.85 | 3094.94 | 1672.2 | 1411.82 | 11489.32 |
| | Number of HH | 1989 | 1989 | 1989 | 1989 | 1989 |
[1] Zhu Ling, senior fellow in the Institute of Economics, Chinese Academy of Social Sciences, Beijing. The paper was drafted mainly based on a study financed by the Beijing Office of the Ford Foundation, The Research Center for Development Studies in University of Bonn, and the Hong Kong Oxfam. Wei Zhong conducted data clean work while Gao Mengtao processed the data and drew the graphs. Lu Aiguo translated a part of the paper from Chinese into English. The Institute of Social Studies in The Hague, the Self-Employed Women’s Association in Ahmedabad, and the Center for Development Studies in Thiruvananthapuram arranged a training course from Jan.15 to March 27, 2003 on social protection issues from which the author greatly benefited for formulating and improving the paper. Sincere appreciation is then expressed here to these institutions and individuals for all of their support and assistances. The author owes deep gratitude to Mr. Kretschmer, who did a part of English editing of this paper right before he passed away. Truthful thanks are presented to Mr. Blair, who completed the rest of the work that Mr. Kretschmer left. Email: zhuling@cass.org.cn
[2] Cf. April 25, 1985, “The State Council Notice on the Report by the Ministry of Public Health on Reform Policies concerning Health Work” (Guowuyuan pizhuan weishengbu guanyu weisheng gongzuo gaige ruogan zhengce wenti de baogao de tongzhi). This policy document considers that one of the main causes for the slow development of health enterprises is insufficient financing, a severe shortage of investment in public health, low medical fees, and operational losses incurred by medical institutions. The next major cause is strict policy restrictions, which are not conducive to stimulate non-state investment. For these reasons, the document encourages collectives or individuals to set up medical institutions, allows the existing medical institutions to increase fees charged, and allows prevention services and supervision services to charge for labor fees and cost recovery fees. www. jkcj.yeah.net
[3] Cf. Health Statistical and Information Center of the Ministry of Public Health, 2002, National Health Expenditure in Various Periods, in 2001 China Health Statistics Abstract, issued in the website: www.moh.gov.cn/statistics/digest01
[4] According to author’s investigation in Nong’an county and Yongji county of Jilin Province in November, 2001, the government no longer provides subsidies to township hospitals while the subsidies provided to county hospitals only for their investment program.
[5] The second state report on health service pointed out: “80% of the health expenditure made by the State and financial departments at various level have been concentrated in the cities, of which 80% was concentrated in big urban hospitals.” Cf. Ministry of Public Health, 1999, p. 188.
[6] The rural poverty line set by the Office of Leading Group for Poverty Alleviation, under the State Council, was 625 yuan per capita annual net income at the end of the 20th century. The exchange rate is 8 yuan=US$1.
[7] Since the beginning of the reforms, the National People’s Congress has passed 9 laws, the State Council announced or rectified 25 administrative regulations, and public health authorities promulgated over 400 department rules concerning health care issues. Cf. Ministry of Public Health and State Chinese Medicine Management Bureau, 2002, p.1.
[8] Sen argues: “These social security provisions are essentially supplementation of the process of market exchange and production, and the two types of opportunities together determine a person’s exchange entitlements in a private ownership market economy with social security provision” (Amartya Sen, Poverty and Famines, p.6, oxford: Clarendon Press 1981).
[9] Burgess and Stern define social security in developing countries as “public action at the household, community, and State level to remove or reduce deprivation and vulnerability.” (See Robin Burgess and Nicholas Stern, “Social Security in Developing Countries: What, Why, Who, and How?” in Ahmad Ehtisham, Jean Dreze, John Hills and Amartya Sen, eds. Social Security in Developing Countries, Oxford: Clarendon Press, 1991, , pp.45-46.) However, this sense is expressed here by the phrase “social protection systems” e while the term “social security” used in this paper refers to formal social protection schemes that are consistent with the usage in present-day China.
[10]The Ministry of Health, 1999, Research of the State Health Service—An Analysis of the Second Survey of the State Health Service in 1998, pp. 89-95, 181-192, Beijing.
[11] The author organized the sample survey during 1999-2000 in collaboration with colleagues from the Research Center for Rural Economic Policies under the Ministry of Agriculture. The survey was conducted on 2,500 households in 34 villages, 34 counties, and 6 provinces (Guangdong, Jiangsu, Hebei, Jilin, Sichuan and Gansu) in 1999. The valid questionnaires total 1,989.
[12] The poverty line defined in our sample was about 1000 yuan per capita annual net income taking into consideration also basic needs for education and health in addition to the bundle of other basic consumption goods and services. This amount of the income was equivalent to half of the national average level at the end of the 1990s.
[13] Ministry of Public Health of P. R China, 1999, Research of the State Health Services –Analytical Report of the Second State Health Service Survey 1998, Table 2-7-10, www.moh.gov.cn.
[14] Here “intervention” refers to public actions taken by the government in health service and health insurance, e.g. investment in public health projects through public financing, regulating the market using regulations and policies, assisting the poor, etc.
[15] Cf. J. Kornai and K. Eggleston, 2003, Zhuangui zhong de fuli. Xuanze he yizhixing, dongou guojia weisheng bumen gaige (Welfare, Choice and Solidarity in Transition—Reforming the Health Sector in Eastern Europe), Chinese edition, pp. 147-154, Beijing: Zhongxin chubanshe
[16] The information about India’s experience in public health service provisions and innovations in establishing insurance programs for informal workers were acquired from the training programs in which the author participated during the period of February- March 2003, in Gujarat and Kerala, India.
[17] Source: Kannan, K. P, 2002, “The Welfare Fund Model of Social Security For Informal Sector Workers: The Kerala Experience”, printed by the Center for Development Studies, Working Paper Series no. 332, pp.38-40.
[18] The exchange rate was about Rs.50=1US$ in India during February-March, 2003.
[19] The author argued in favor of a social insurance program designed to cover the risk of specific infectious diseases in the paper “To Start from Establishing universal health insurance against infectious diseases,” published in the journal of Financial Studies, date no.7, p. 16-24.
[20] The data source for the tables and the diagrams that are not specifically indicated are from the sample survey that the author organized during 1999-2000 in collaboration with colleagues from the Research Center for Rural Economic Policies under the Ministry of Agriculture, China. The survey was conducted on 2500 households in 34 villages, 34 counties, 6 provinces (Guangdong, Jiangsu, Hebei, Jilin, Sichuan and Gansu) in 1999. The valid questionnaires count up to 1989.
Tags：Restructuring,The,Basic,Health,Protection,System,in,Rural,China
责任编辑：admin相关文章列表
[ 查看全部 ] 网友评论