MATERIAL Y MÉTODOS

As previously explained, Government (including the Central Government) organises, governs, funds and operates the new RCMS. The fiscal subsidy system underpinning the Scheme will only work efficiently by following the principle of “the lower the income, the higher the subsidies”. In its implementation, a priority goal was to ensure

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that funding progressively increased. Only in this way could the reimbursement rate increase correspondingly and more rural patients would benefit. Funding increases have mainly depended on increased government subsidy. Since 2005, the subsidy has indeed grown to an average of 80 per cent of the total funding available, although in some rich provinces the proportion contributed by local government is much higher.

A primary aim of the new RCMS was to provide the same type of government subsidy as Medicaid for rural patients with serious illnesses, in order to prevent them from falling into poverty. Accordingly, the subsidy should be higher for persons on lower incomes. In practice, the opposite seems to be the case. For example, in 2008, the average earnings per capita for east, mid and west rural Chinese were 7238.7 CNY, 4551.04 CNY, and 3481.25 CNY respectively, but the subsidy per capita was on average 44.265 CNY, 35.61 CNY, and 35 CNY respectively (Ren, 2010).

Apart from funding, government bodies are also responsible for a range of other functions within the new RCMS. Three key roles – coordination, supervision and

‘watchdog’ – are assigned to the county government level.

Coordination

At present, RCMS fees are collected by each county. Levels of both funding and reimbursement are decided by the principle that costs should not exceed income. The

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success or failure of the new RCMS will be determined by the extent to which it is able to limit medical costs.

When the new RCMS was put into practice, the greatest problem was how to control these costs, especially the price of medicines. In order to accomplish this, some form of overall coordination is needed. At present, for example, the responsibility for medicine supervision belongs to the Ministry of Health. But responsibility for production of medicines belongs to the industry itself and is supervised by the National Development and Reform Commission, under which there is a price administration department in charge of the price of medicines. Therefore, in order to limit medical cost, there is a need to negotiate among those administrative organisations involved. In recent years, this issue has come to the attention of the Chinese Government, specifically in relation to the cost of medicines in primary care organisations and those on the essential medicines list. The Government has introduced a “zero profit” policy to contain the costs of these medicines.

Supervision

At present the Scheme provides considerable opportunity for hospitals to pursue their own economic interests rather than those of their patients. A recent survey (Chen and Hua, 2009), for instance, showed that some hospitals charge randomly and above the market price. As well, some doctors routinely prescribe costly medicines for patients,

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including those that fall outside of the official prescribing catalogue and therefore do not attract any reimbursement.

Another study (Xue, 2009) reveals equally problematic arrangements whereby the county supervisory office of the new RCMS was located in the County Public Health Bureau, and the township supervisory office was in the township hospital. This means the supervisor was also a worker in the medical service - a case of ‘the police policing themselves’. The study also found that 83.5 per cent of designated health centres and 64.1 per cent of designated township hospitals charged above the prescribed, regulated price.

Whether in the medical service market or with the supervisory office of the new RCMS, it seems, there are still many problems to be addressed. According to one delegate at the third session of the 11^th National People’s Congress in March, 2010 (Xia, 2010): “in every province (municipality and area directly under the jurisdiction of the Central Government) most of the new RCMS offices are temporary, and they have the same staff who perform the same work as they did when it was a local government office”. In general, the new RCMS office is in a borrowed room in a township hospital, with no permanent staff and no additional financial outlay.

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Watchdog

Another important task for the new Scheme is to address the problem of illegal and criminal dealings in the rural healthcare market. These include practices such as taking bribes in the drug business, “quack” doctors deceiving patients, selling pseudo-medicines, charging randomly, embezzling funds or using funds for other, illegal purposes.

As Chen and Hua (2009) point out, such problems cannot be dealt with under existing policies, which are developed by the county government or department concerned.

This is because up until now, the Scheme has been administered under so-called ‘soft laws’ which leave it open to misappropriation of funds and other fraudulent activities.

Promotion and publicity

In a recent survey (Zhu, 2007), about half of respondents indicated their main reason for deciding to participate in the new RCMS was because others had done so. Only 30.8 per cent of survey respondents understood the meaning of the new RCMS and had a positive attitude towards it. When asked about their degree of satisfaction with how the Scheme had been promoted and publicised, 24.1 per cent were very dissatisfied, 45.5 per cent were dissatisfied, and only 30.4 per cent were satisfied.

Older Miao People and Rural Health Policy in China Lin Yuan, University of Sydney, 2012

Many rural survey respondents said they joined the Scheme in the expectation that it would bring benefits for their family. Later, when they experienced an illness, they found there were many medical expenses that could not be reimbursed - for example, for outpatients and those with chronic diseases. Moreover, the procedure for accessing private or public health care and the procedure for applying for reimbursement was much more complex for members than for non-members of the new RCMS, and medical expenses were much higher as well, with the result that (even with the reimbursement) there was no obvious difference between being a member or not (Zhu, 2007).

Clearly the Government has not promoted the scheme well, and has failed adequately to inform the rural population about which conditions could be reimbursed and which could not, or to explain the responsibilities of the different hospital levels.

Agricultural workers in particular were very dissatisfied with the new RCMS, and especially with the township hospitals.