How does the New Cooperative Medical Scheme influence health service utilization? A study in two provinces in rural China

BMC Health Services Research RHesoeawrch adrtioclees the New Cooperative Medical Scheme influence health service utilization? A study in two provinces in rural China Baorong Yu Qingyue Meng Charles Collins Rachel Tolhurst 0 Shenglan Tang 0 Fei Yan Lennart Bogg Xiaoyun Liu 0 0 Liverpool School of Tropical Medicine , Pembroke Place, Liverpool, L3 5QA , UK Background: Many countries are developing health financing mechanisms to pursue the goal of universal coverage. In China, a rural health insurance system entitled New Cooperative Medical Scheme (NCMS) is being developed since 2003. Although there is concern about whether the NCMS will influence the serious situation of inequity in health service utilization in rural China, there is only limited evidence available. This paper aims to assess the utilisation of outpatient and inpatient services among different income groups and provinces under NCMS in rural China. Methods: Using multistage sampling processes, a cross-sectional household survey including 6,147 rural households and 22,636 individuals, was conducted in six counties in Shandong and Ningxia Provinces, China. Chi-square test, Poisson regression and log-linear regression were applied to analyze the association between NCMS and the utilization of outpatient and inpatient services and the length of stay for inpatients. Qualitative methods including individual interview and focus group discussion were applied to explain and complement the findings from the household survey. Results: NCMS coverage was 95.9% in Shandong and 88.0% in Ningxia in 2006. NCMS membership had no significant association with outpatient service utilization regardless of income level and location. - Background Many low and middle income countries are seeking ways to pursue the goal of universal coverage. To secure access to adequate health care for all at an affordable price, it will be necessary to increase the extent of prepayment and reduce the reliance on out-of-pocket payment [1,2]. Tax-based health financing and social health insurance, or a mix of them, are the most frequently used mechanisms for achieving this goal. The Chinese government has been developing rural health insurance (Cooperative Medical Scheme, CMS) since the 1950s. By the late 1970s, approximately 90% of the rural population were covered by the CMS. The shift to a market economy and the demise of the rural communes in the 1980s was matched by the related decline in the CMS [3]. This left large sectors of the rural population uncovered by health insurance despite attempts by central and local governments to revive similar schemes in the 1990s [4]. In 2002 the State Council and the Central Committee of the Communist Party of China initiated the policy of the New Cooperative Medical Scheme (NCMS). This is a 'voluntary' and heavily subsidised scheme designed to reduce the financial burden of illness on the rural population. The Ministry of Health takes the overall responsibility to manage and supervise the scheme while the policy implementation responsibilities are decentralized to county level governments. The NCMS mainly covers inpatient services. It has been calculated that by the end of 2009, 95.3% of all counties and 91.5% (815 million) of the rural population would be covered by the NCMS [5]. Economic and health sector reform in China have been leading to increased inequity in health care, especially in rural areas [6,7]. Lack of health insurance, among many other factors, has been one of the main reasons contributing to this inequity [8-10]. While the expansion of NCMS coverage since 2003 is impressive, there is, however, concern over whether these coverage rates are matched by improvements in the utilisation of health services, and how the impact differs between different income groups [11-13]. In other words, although the NCMS aims in part to improve access to health services [14], it is not clear to date how the severe situation of inequity in access to health services has changed after the introduction of NCMS. An increasing body of studies published in Chinese have attempted to evaluate the effect of NCMS on health care utilization, but have presented contradictory findings in terms of outpatient and inpatient service utilization [15-17]. None of these studies have done a careful analysis on the confounding factors which may influence health service utilization. Studies published internationally have also analysed the NCMS [11,12], but these studies have mainly focused on the impact of NCMS on financial protection. We found only one internationally published study examining the impact of NCMS on health service utilization [13]. This is a quantitative study in 2005 comparing NCMS impact in 10 NCMS counties and 5 non-NCMS counties. It concluded that the NCMS has increased both outpatient and inpatient service utilization. The aim of this paper is to assess the utilisation of health services under NCMS in two provinces of China. The study will compare the service utilization between NCMS members and non-members. Particular attention will be paid to the type of health services (outpatient and inpatient) and how the changes in health service utilization differ among different income groups and provinces. The importance of the paper is twofold. Firstly, it contributes to the limited evidence on health service utilization under NCMS, paying particular attention to utilisation differences between socio-economic groups. Secondly, the paper combines both quantitative and qualitative methods, the combination of which provides particularly rich explanatory data. This study used a cross-sectional household survey to analyze the health service utilization among different income and regional groups under NCMS. Individual interviews, focus group discussions (FGD) and secondary data analysis were used to explore possible factors influencing health service utilization. The study was conducted in Shandong and Ningxia Province, the choice of which allowed for analysis in different socio-economic and regional environments. Shandong is located in the more developed eastern coastal area and had a GDP per capita of 23,546 Yuan (about 3,139.5 US$) in 2006. Ningxia, a poor area in north western China, had a GDP per capita of 11,784 Yuan (about 1,571.2 US$) in 2006 and 36% of its population are ethnic minority groups. Three counties from each province were selected for the project. This selection was based on the following criteria: 1) all the counties had implemented NCMS, 2) the county governments were willing and able to collaborate with the research project, and 3) the three counties had different socio-economic development status representing the low, middle and high level of socioeconomic development within the province. The household survey used multistage sampling processes. Three townships in each county and six villages in each township were selected using similar criteria as the selection of counties. In each village, (...truncated)