In 2002, the Chinese leadership announced a change in national welfare policy: Voluntary medical schemes at county level, called the “New Rural Co-operative Medical System” should cover all counties by 2010. This article addresses the main characteristics of this system, analyses the introduction of local schemes based on our own field studies in one Kazak county of the Xinjiang Uyghur Autonomous Region since 2006, and argues that the fast progressing of the local scheme and the flexibility shown by local administrators in considering structural and procedural adjustments are not the result of central directives but of local initiatives. Recentralization from the township governments to functional departments in the provincial and the central state administration is only one aspect of current rural governance. Complementary forms of locally embedded responsiveness to the needs of health care recipients are crucial in restructuring the administration and discharge of health care. These new modes of governance are different from the hierarchical control and institutionalized representation of interests of the local population.
1 NRCMS definition in 2003: “[It] provides mutual help and benefit, mainly focusing on and curing heavy diseases. It is organized, led and supported by the government and with voluntary participation of the farmers. The system is financed jointly by individuals, collectives and government,” “Guanyu jianli xinxing hezuo yiliao zhidu yijian” (“Opinions about the introduction of NRCMS”), Guobanfa, No. 3 (16 January 2003), http://www.jswst.gov.cn/dfnewsdisplay.php?newsid=436, accessed 13 May 2006.
2 “Zhonggong zhongyang guowuyuan guanyu jin yibu jiaqiang nongcun weisheng gongzuo de jueding” (“Decision of the Central Committee of the CP and the State Council to strengthen health work in rural areas”), Zhongfa, No. 13 (30 October 2002), http://www.agri.gov.cn/zcfg/t20021107_22649.htm, accessed 3 April 2003. This policy was expanded to other regions in 2006. “Guanyu jiakuai tuijin xinxing nongcun hezuo yiliao shidian gongzuo de tongzhi” (“Circular about speeding up the introduction of pilots of NRCMS”), Weinongweifa, No. 13 (19 January 2006), http://www.moh.gov.cn/public/open.aspx?n_id=11283, accessed 12 May 2006.
3 See the following regarding the Co-operative Medical System before 2002: Yuanli, Liu, Rao, Keqin and Hu, Shanlian, People's Republic of China. Toward Establishing a Rural Health Protection System (Manila: Asian Developing Bank, 2002), http://www.adb.org/documents/reports/RC_rural_health_protection_system/prc_rural_health.pdf, accessed 26 November 2004; Klotzbücher, Sascha, Das ländliche Gesundheitswesen der VR China. Strukturen – Akteure – Dynamik (Frankfurt am Main: Peter Lang, 2006). Regarding the NRCMS see Weisheng tongji xinxi zhongxin, Zhongguo xinxing nongcun hezuo yiliao jinzhan jiqi xiaoguo yanjiu (Research on Development and Effectiveness of China's New Rural Co-operative Medical Scheme) (Beijing: Zhongguo xiehe yiyuan daxue chubanshe, 2007); Yuanli, Liu, “Development of the rural health insurance system in rural China,” Health Policy and Planning, Vol. 19, No. 3 (2004), pp. 159–65. Duckett, Jane, “Local governance, health financing, and changing patterns of inequality in access to health care,” in Shue, Vivienne and Wong, Christine (eds), Paying for Progress in China: Public Finance, Human Welfare and Changing Patterns of Inequality (London: Routledge, 2007), pp. 46–68; Hong, Wang, Licheng, Zhang, Yip, Winnie and Hsiao, William, “Adverse selection in a voluntary rural mutual health care health insurance scheme in China,” Social Science & Medicine, Vol. 63, No. 5 (2006), pp. 1236–45; Jackson, Sukhan, Sleigh, Adrian C., Peng, Li and Xi-li, Liu, “Health finance in rural Henan: low premium insurance compared to the out-of-pocket system,” The China Quarterly, No. 181 (2005), pp. 137–52.
4 This article does not discuss the minority population aspects, and how they might affect the “responsiveness” of the administrators.
5 See Treib, Oliver, Bähr, Holger and Falkner, Gerda, “Modes of governance: towards a conceptual clarification,” Journal of European Public Policy, Vol. 14, No. 1 (2007), pp. 1–20 at pp. 5–11. An example is Dali, Yang, Remaking the Chinese Leviathan: Market Transition and the Politics of Governance in China (Stanford: Stanford University Press, 2004).
6 O'Brien, Kevin and Lianjiang, Li, Rightful Resistance in Rural China (Cambridge: Cambridge University Press, 2006).
7 See Bossert, Thomas, “Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance,” Social Science and Medicine, Vol. 47, No. 10 (1998), pp. 1513–27.
8 Weigelin-Schwiedrzik, Susanne, “The distance between state and rural society in the PRC. Reading document No. 1 (February 2004),” Journal of Environmental Management, Vol. 87, No 2 (2008), pp. 216–25.
9 Definition slightly changed, see Alma De Silva, A Framework for Measuring Responsiveness. GPE Discussion Paper Series No. 32 (no year), http://www.who.int/responsiveness/papers/paper32.pdf, accessed 6 November 2007. Responsiveness, originally developed in economic studies of the principal-agent theory, is used for the relationship between central and local state agencies (Klotzbücher, Gesundheitswesen, pp. 151, 169ff). Further, it is developed in the WHO Health 2000 report as “to assess, monitor and raise awareness of how people are treated and the environment in which they are treated when seeking health care.” See World Health Organisation (WHO), Health System Responsiveness, http://www.who.int/responsiveness/en/, accessed 23 October 2007.
10 See further Sascha Klotzbücher and Peter Lässig, “Transformative state capacity in post-collective China: the introduction of the ‘New Rural Cooperative Medical System (NRCMS)’ in two counties of Western China, 2006–2008,” European Journal of East Asian Studies, Vol. 8, No. 1 (2009), pp. 61–89. Regarding the importance of feedback loops in other policy fields, see Heilmann, Sebastian, “Policy experimentation in China's economic rise,” Studies in Comparative International Development, Vol. 43, No. 1 (2008), pp 1–26.
11 “Guanyu nongcun weisheng gaige yu fazhan de zhidao yijian” (“Suggestions about the reform and management in rural health care”), Guobanfa, No. 39 (8 May 2001), http://www.moh.gov.cn/newhtml/8065.htm, accessed 30 July 2007.
12 Guobanfa, No. 3 (2003).
13 Zhongfa, No. 13 (2002).
14 Klotzbücher, Gesundheitswesen, pp. 205–40.
15 Ibid. pp. 176ff.
16 Zhongfa, No. 3 (1997), para. 33, Guobanfa, No. 3 (2003).
17 Guobanfa, No. 3 (2003).
18 “Weishengbu, caizhengbu, guojia zhongyiyao guanliju guanyu wanshan xinxing nongcun hezuoyiliao buchang fang'an de zhidao yijian” (“Guiding suggestions of the MoH, MoF, and the State Administration of Traditional Chinese Medicine for the completion of the subsidy scheme for the NRCMS”), Weinongweifa, No. 235 (2007)), http://www.moh.gov.cn/newshtml/20180.htm, accessed 30 September 2007.
19 Zhongfa, No. 2 (2002).
20 Coverage (fugai) in this context means only the availability of a scheme in a county.
21 Weinongweifa, No. 13 (2006).
22 “Caizhengbu, weishengbu guanyu zhongyang caizheng zizhu zhongxibu diqu nongmin canjia xinxing hezuoyiliao zhidu buzhu zijin bofu youguan wenti de tongzhi” (“Circular of the MoF and MoH about the appropriation of sums that the central budget deems appropriate for subsidies of the enrolled peasants from Western and Central regions”), Caishe, No. 112 (25 August 2003), http://www.moh.gov.cn/newshtml/8353.htm, accessed 30 September 2007.
23 Weinongweifa, No. 13 (2006).
24 Guobanfa, No. 3 (2003).
25 Zhongfa, No. 13 (2002).
26 Interview 16/07.
27 Yili hasake zizhizhou tongjiju (ed.), Yili hasake zizhizhou tongji nianjian 2006 (2006 Statistical Yearbook of the Yili Kazak Autonomous Prefecture) (Wulumuqi: Yili hasake zizhizhou tongjiju, 2006), p. 63.
28 Interview 01/07.
29 Interviews 16/07 Q/A 3 and interview 18/07.
30 Interview 05/07.
31 See Mertha, Andrew, “China's ‘soft’ centralization: shifting Tiao/Kuai authority relations,” The China Quarterly, No. 184 (2005), pp. 791–810, at p. 792; Klotzbücher, Gesundheitswesen, pp. 142ff.
32 Xinyuan xian (Xinyuan County), Xinyuan xian xinxing nongmuqu hezuo yiliao shishi xice (shixing) (Concrete NRCMS Implementation Guidelines for Agricultural and Pastoral Regions in Xinyuan County) (Document, 2006); interview 14/07 para.1.
33 Interview 02/07 paras. 2 and 3.1. Regarding the discussion of the relationship of the functional administrative superiors and leadership of local government, see Mertha, “China's ‘soft’ centralization,” p. 797.
34 Zhongfa, No. 13 (2002).
35 Xinyuan County, NRCMS Implementation Guidelines 2008, para. 18.4.
36 Interview 02/07 para. 3.4.
37 Interview 16/07 Q/A 11.
38 Xinyuan County, NRCMS Implementation Guidelines 2008, art. 25–28.
39 Interview 05/07 para.2.
40 Interview 16/07 Q/A 4.
41 Interview 16/07 Q/A 5.
42 Guobanfa, No. 3 (2004).
43 For example, if the bill in a township hospital amounts to 1,500 yuan, the amount reimbursed according to 2007 rates will be (1,500-80(excess)) x 70% (reimbursement rate) = 994 yuan or 66%. Not included is that approx. 20% of the drugs or services are not reimbursable. This would lower the reimbursement rate to 53% (2007) or 37% (2006). Applying 2006 rates to the same example, the reimbursement would only have amounted to 700 yuan (47%). All expenses above the ceiling of 8,000 yuan must be borne by the patient.
44 Interview 08/06, table.
45 See exclusion list in Xinyuan County, NRCMS Implementation Guidelines 2008, art. 23.
46 Interviews 01/07, 05/07.
47 Xinyuan County, NRCMS Implementation Guidelines 2008, art. 22, and Xinyuan xian (Xinyuan County), Xinyuan xian nongmu min canjia xinjin nongmu qu hezuo yiliao xieyi shu (NRCMS Participation Agreement of Farmers and Herders in Xinyuan County) (Document 2007), para. 7.
48 Interview 05/07 para. 4.
49 Shihezi daxue, weiyena daxue (Shihezi/Vienna Universities), “Xinyuan xian muqu jumin weisheng fuwu xianzhuang ji muye yiyuan fazhan qianjing yanjiu” (“The current situation of health care service for herders in Xinyuan and the research about the development prospects for the pastoral hospitals”), unpublished, 2007, p. 66.
50 Shihezi/Vienna Universities, Xinyuan Pastoral Health Services, table 2-5-5; p. 31.
51 Jun, Han and Dan, Luo, Zhongguo nongcun weisheng diaocha (Survey on China's Rural Medical and Health Reality) (Shanghai: Yuandong chubanshe, 2007), p. 397.
52 Interview 16/07 Q/A 8.
53 Interview 16/07 Q/A 10.
54 Interview 12/07 para.3.
55 Interview 16/07 Q/A 7.
56 Xinyuan County, NRCMS Participation Agreement, para. 7.
57 Shihezi/Vienna Universities, Xinyuan Pastoral Health Services, p. 59.
58 Interview 11/07.
59 Interview 02/08.
60 Our focus interviews and health survey was also valuable customer feedback to the administrators.
61 Shihezi/Vienna Universities, Xinyuan Pastoral Health Services, p.59.
62 Xinjiang zhengxie (Xinjiang's Political Consultative Conference), “Di 519 hao guanyu jinyibu zuohao woqu xinxing nongmuqu hezuo yiliao shidian gongzuo de jidian jianyi” (“Document No. 519 about suggestions to finish the pilot NRCMS in agricultural and pastoral regions”) (30 May 2006), http://www.xjzx.gov.cn/showcontent.asp?id=4263&Nclassid=191, accessed 8 July 2008.
63 “Minzhengbu, weishengbu caizhengbu guanyu shishi nongcun yiliao jiuzhu de yijian” (“Suggestions of the Ministry of Civil Affairs, MoH, and MoF about the implementation of the medical financial assistance”), Minfa, No. 58 (18 November 2003), http://www.moh.gov.cn/public/open.aspx?n_id=8365, accessed 12 May 2006; Duckett, Health Financing, p. 56ff.
64 Shihezi/Vienna Universities, Xinyuan Pastoral Health Services, p.559 and interview 05/07 para.2; Interview 16/07.
65 E.g. X-rays 11–28 yuan, ultrasound and ECG 6-30 yuan, injections 1–4 yuan, blood/urine analysis 5–13 yuan, registration and examination fees 0.3 and 0.5 yuan. Interview 08/06.
66 Interview 05/07, para.2.
67 Interview 18/07 Q/A 9.
68 Interview 18/07.
69 “Guanyu nongcun weisheng jigou gaige yu guanli de yijian” (“Suggestions about the reform and management of the rural health care institutions”), Weijifufa, No. 315 (24 December 2002), http://www.moh.gov.cn/jcwsyfybj/zcxx/ncws/1200301060004.htm, accessed 4 August 2003.
70 See Guobanfa, No. 3 (2003).
71 Interview 18/07.
72 Interview 02/08.
73 Xinyuan County, NRCMS Implementation Guidelines, paras. 27, 30 and 31.
74 Interview 05/06.
75 Interview 05/07.
76 Whiting, Susan, “The cadre evaluation system at the grass roots: the paradox of party rule,” in Naughton, Barry J. and L.Yang, Dali (eds), Holding China Together: Diversity and National Integration in the Post-Deng Era (Cambridge: Cambridge University Press, 2004), pp. 1–25; Yang, Chinese Leviathan, pp. 231ff.
77 Klotzbücher, Gesundheitswesen, p. 268.
78 Weigelin-Schwiedrzik, Reading Document No. 1.
79 Tsai, Lily L., “The struggle for village public goods provision: informal institutions of accountability in rural China,” in J.Perry, Elizabeth and Goldman, Merle (eds), Grassroots Political Reform in Contemporary China (Cambridge, MA: Harvard University Press, 2007), pp. 117–48.
80 Klotzbücher, Gesundheitswesen, pp. 211ff.
81 Xinyuan County, NRCMS Implementation Guidelines, para. 8.
82 Interview 18/07, para.8.
83 Treib, Bähr and Falkner, Governance, pp. 6–15.
* Financial support has come from the Austrian Science Fund (FWF) and the Eurasia Pacific Uninet. The authors would like to thank Rui Dongsheng and eight Kazak graduate students for conducting the health survey in 2006 and all interviewees.
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