An evaluation of China's new rural cooperative medical system: achievements and inadequacies from policy goals.
BACKGROUND
Although much public scrutiny and academic attention has focused on the evaluations of system implementation since the beginning of New Rural Cooperative Medical System (NRCMS) in China, few studies have systematically evaluated the achievements of the stated policy goals. The purpose of this study is to examine to what extent the policy goals of NRCMS have been achieved.


METHODS
Using multistage sampling processes, two rounds of cross-sectional household surveys including 9787 and 7921 rural households were conducted in Eastern China in year 2000 and year 2008, respectively. A pre- and post-implementation comparison was used to evaluate the achievement of policy goals in three measures: impoverishment from major health hazards, household financial risk from medical expenses, and rural income inequity. Intention surveys were also applied to find out potential obstacles in the implementation of NRCMS.


RESULTS
The rate of re-impoverishment from health hazard was reduced from 2.69 % ex ante to 2.12 % ex post, a decrease of 21.13 %. The severity of impoverishment fell from a previous 4.66 % to 3.02 %, a decline of 35.18 %. Economic risk of medical treatment population relative to the whole population fell from 2.62 ex ante to 2.03 ex post, a 22.52 % reduction. As indication of effect on improving income equity, the Gini coefficient fell from 0.4629 to 0.4541. The effects of NRCMS were significantly better than those of RCMS. Despite the preliminary achievements, our intention survey of key respondents identified that technical difficulties in actuarial funding and more sustainable reimbursement schedules has become the most challenging barriers in achieving the goals of NRCMS, while raising the insurance premium on NRCMS was no longer as big a barrier.


CONCLUSIONS
With NRCMS, China has established a medical security system to reduce the financial burden of healthcare on rural residents. NRCMS has achieved some positive though limited effects; but technical difficulties in the implementation of NRCMS have become barriers to achieve the pre-set policy goals. Efforts should be made to improve the capacity building in the design of the reimbursement schemes for the implementers of NRCMS, such as identifying medical impoverishment, calculating actuarial funding levels for the risk pooling.
Research Institute of Health Development Strategies, Fudan University, 130 Dong An Road, Shanghai, 200032, China. lichengyue@fudan.edu.cn.|Collaborative Innovation Center of Social Risks Governance in Health, 130 Dong An Road, Shanghai, 200032, China. lichengyue@fudan.edu.cn.
Chengyue
C
Li
Department of Public Administration and International Affairs, Maxwell School of Citizenship and Public Affairs, Syracuse University, 426 Eggers Hall, Syracuse, NY, 13244-1020, USA. yihou@maxwell.syr.edu.
Yilin
Y
Hou
Research Institute of Health Development Strategies, Fudan University, 130 Dong An Road, Shanghai, 200032, China. sunmei@fudan.edu.cn.|Collaborative Innovation Center of Social Risks Governance in Health, 130 Dong An Road, Shanghai, 200032, China. sunmei@fudan.edu.cn.
Mei
M
Sun
Research Institute of Health Development Strategies, Fudan University, 130 Dong An Road, Shanghai, 200032, China. lujun@shmu.edu.cn.|Collaborative Innovation Center of Social Risks Governance in Health, 130 Dong An Road, Shanghai, 200032, China. lujun@shmu.edu.cn.
Jun
J
Lu
Research Institute of Health Development Strategies, Fudan University, 130 Dong An Road, Shanghai, 200032, China. wangying1013@fudan.edu.cn.|Collaborative Innovation Center of Social Risks Governance in Health, 130 Dong An Road, Shanghai, 200032, China. wangying1013@fudan.edu.cn.
Ying
Y
Wang
Research Institute of Health Development Strategies, Fudan University, 130 Dong An Road, Shanghai, 200032, China. lixh@fudan.edu.cn.|Collaborative Innovation Center of Social Risks Governance in Health, 130 Dong An Road, Shanghai, 200032, China. lixh@fudan.edu.cn.
Xiaohong
X
Li
Research Institute of Health Development Strategies, Fudan University, 130 Dong An Road, Shanghai, 200032, China. changfsh@fudan.edu.cn.|Collaborative Innovation Center of Social Risks Governance in Health, 130 Dong An Road, Shanghai, 200032, China. changfsh@fudan.edu.cn.
Fengshui
F
Chang
Research Institute of Health Development Strategies, Fudan University, 130 Dong An Road, Shanghai, 200032, China. haomo03@fudan.edu.cn.|Collaborative Innovation Center of Social Risks Governance in Health, 130 Dong An Road, Shanghai, 200032, China. haomo03@fudan.edu.cn.
Mo
M
Hao
D000124:Achievement; D000328:Adult; D002681:China / Q000453:epidemiology; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000191:economics / Q000458:organization & administration*; D005260:Female; D005378:Financial Support; D005381:Financing, Organized / Q000706:statistics & numerical data; D006040:Goals; D006291:Health Policy / Q000191:economics*; D006801:Humans; D008297:Male; D009313:National Health Programs / Q000458:organization & administration; D019035:Rural Health Services / Q000191:economics / Q000458:organization & administration*; D012424:Rural Population / Q000706:statistics & numerical data*