I MPACT E VALUATION S ERIES N O . 12 Extending Health Insurance to the Rural Population: An Impact Evaluation of
China’s New Cooperative Medical Scheme
by
Adam Wagstaff a , Magnus Lindelow b , Gao Jun c , Xu Ling c and Qian Juncheng c
条件英文a Development Rearch Group, The World Bank, Washington DC, USA
b East Asia Human Development, The World Bank, Washington DC, USA
c Center for Health Statistics an
d Information, Ministry of Health, Beijing, China
Abstract
In 2003, China launched a heavily subsidized voluntary health insurance program for rural residents. We analyze factors affecting enrollment and combine differences-in-differences with matching methods
to obtain impact estimates. We u data collected from program administrators, health facilities and houholds. Enrollment is lower among poor houholds, and higher among houholds with chronically sick members. The scheme has incread outpatient and inpatient utilization (by 20-30%), but has had no impact on out-of-pocket spending or on utilization among the poor. The program has incread ownership of expensive equipment among central township health centers but has had no impact on cost per ca.
Corresponding author and contact details: Adam Wagstaff, World Bank, 1818 H Street NW, Washington, D.C. 20433, USA. Tel. (202) 473-0566. Fax (202)-522 1153. Email: awagstaff@worldbank .
Keywords: China; health insurance; cooperative medical scheme; impact evaluation.
Acknowledgements: The rearch reported in the paper began as a background paper for a larger World Bank study of rural health reform in China, details of which are available at www.worldbank/chinaruralhealth . The larger study was task-managed by L. Richard Meyers, and financially supported by the World Bank and the UK’s Department for International Development. We are grateful to staff from the Ministry of Health in China for support and technical a
dvice, to Shengchao Yu and Helena Chang for their help in designing and fielding the survey and in organizing and analyzing the data, and to Bert Hofman for helpful comments on an earlier version of the paper.
World Bank Policy Rearch Working Paper 4150, March 2007 The Policy Rearch Working Paper Series disminates the findings of work in progress to encourage the exchange
notionalof ideas about development issues. An objective of the ries is to get the findings out quickly, even if the prentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expresd in this paper are entirely tho of the authors. They do not necessarily reprent the view of the World Bank, its Executive Directors, or the countries they reprent, or of the Government of China. Policy Rearch Working Papers are available online at econ.worldbank.
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WPS4150P u b l i c D i s c l o s u r e A u t h o r i z e d P u b l i c D i s c l o s u r e A u t h o r i z e d
I.INTRODUCTION
Several developing countries have recently ud tax revenues to subsidize health insurance for infor
mal ctor (usually rural) workers and their families, or at least the poorer ones among them. In Colombia, the Philippines and Vietnam, for example, the poor are enrolled in the national social health insurance scheme at the taxpayer’s expen. The rest of the informal ctor either have the option of enrolling (in the cas of the Philippines and Vietnam) or are required to enroll (in the ca of Colombia). In all three countries, the houhold enrolls at its own expen though the contribution paid by nonpoor voluntary enrollees is sometimes subsidized (it is, for example, in the ca of Vietnam). In China and Mexico, by contrast, houholds not covered by formal ctor programs (albeit only rural houholds in China) have the option of enrolling in a parate subsidized public health insurance program. In both countries, the contribution is to some degree linked to houhold income, with poor houholds having their contribution paid entirely by the taxpayer, and nonpoor houholds either paying a subsidized flat-rate contribution (the ca in China) or an income-related contribution (the ca in Mexico).1 Thailand recently opted for a third route, which was to enroll at the taxpayer’s expen all tho not covered by the various programs for formal-ctor workers.2
This paper reports the results of an impact evaluation of China’s scheme. The program, which began in 2003 and is being rolled out on a staggered basis with all rural county-level jurisdictions (hereafter counties3) to be covered by 2008, replaces China’s old village-bad rural health insurance program,
known as the cooperative medical system or CMS.4 That scheme all but disappeared following the collap of the commune system in the early 1980s when China embarked on its market-oriented economic reforms.5 As of September 2006, an estimated 406
1 To date, Mexico’s scheme has targeted the poorest decile which is not liable for contributions.
2 On Colombia e Escobar and Panoplou (2003), on Mexico e Knaul and Frenk (2005) and Scott (2006), on the Philippines e Obermann et al. (2006), on Thailand e Pannarunothai et al. (2004), and on Vietnam e Knowles et al. (2005).
3 County-level governments in China include urban districts, county-level cities, and counties. The new program is targeted at rural residents. Most (but not all) reside in counties; urban districts and county-level cities containing rural residents will also receive the program.
4 The primary stated aim of the scheme is to reduce impoverishment resulting from illness (Central Committee of CPC 2002). In 2003, piloting of the scheme began in around 300 of China’s more than 2000 rural counties in 2003 (Liu 2004; World Bank 2005). By 2005, the scheme had been expanded to over 600 counties.
5 The CMS is often argued to be at least partly responsible for China’s remarkable achievements in reducing mortality during the early years of the People’s Republic (Sidel 1993). This program was premid on mandatory contributions to the village production brigade or collective welfare fund, and ensured access to basic medical rvices for China’s rural population. In most part of China, CMS did not survive the de-collectivization of agriculture in the early 1980s, whereby village collective welfare funds were dismantled (Zhu et al. 1989; Liu 2004). Indeed, by 1993, less than 7 percent of the rural population was covered by
the NCMS. There have been various attempts to resuscitate the CMS, including included the RAND Sichuan CMS experiment in mid-1990s (Cretin et al. 1990), the WHO 14 county study in the early 1990s (Carrin et al. 1999), the UNICEF 10- county study
million people were enrolled the new scheme, which was up and running in over half (1,433) of China’s rural counties. The establishment of the new CMS or NCMS, as the new program is known, was a respon to accumulating evidence that high and rapidly rising ur charges were causing widespread poverty and deterring families—especially poor ones—from using health facilities.6 The program—which unlike its predecessor operates at county rather than village level, and exhibits variations in design and implementation across counties—is financed in part through flat-rate houh
old contributions (the poor and certain other groups have their contributions subsidized) and in part through government subsidies, with central government helping county governments in China’s poorer provinces with the local government contribution.
One concern with the program is that its budget is too small to make a significant dent in houholds’ out-of-pocket spending. The revenue per enrolled is around only one-fifth of total per capita rural health spending, and copayments in the scheme are high, reflecting large deductibles, low ceilings, and high coinsurance rates. It is, in fact, possible that becau the scheme is likely to encourage people to ek care who would not otherwi have done so, and becau providers in China are paid fee-for-rvice through a price schedule that results in higher margins on drugs and high-tech care than on ‘basic’ rvices (Liu and Mills 1999), insurance may result in incread utilization of expensive care, and hence out-of-pocket spending may actually increa; this appears to have happened in China’s urban scheme (Wagstaff and Lindelow 2005). Concerns have also been expresd that the scheme may do little to increa utilization of health rvices among poor houholds becau of the high copayments. Indeed, it has been suggested that the costs may reduce the benefits of the scheme to the poor to such a degree that they may be less likely to enroll. Concerns have also been expresd that the scheme may not attract the relatively good risks, and may therefore suffer from adver lection.26个拼音字母表
This paper attempts to shed light on the and other issues, and in the process to contribute to the more general literature on the impacts of subsidized health insurance programs aimed at informal ctor workers.7 Our focus is on the 189 counties that began implementing NCMS in 2003. We look not only at the impacts on a large sample of houholds in a subt of in 1997-2000, the World Bank Health VIII project in the late 1990s, and the Harvard 2-county study in 2003 (Hsiao and et al. 2004). Many of the schemes suffer from poor administration and small risk pools. Moreover, the voluntary nature of the schemes tends to result in adver lection. Hence, despite the efforts , coverage remained low throughout the 1990s, and by 2003, 80% of China’s rural population—some 640 million people—lacked health insurance (Ministry of Health Center for Health Statistics and Information 2004).美剧黑名单
6 See, for example, Liu et al. (2003), Liu et al. (2004), and Yuan et al. (1998).
7 We discuss below the findings from this literature, in the context of our discussion of the findings from the prent study.
the counties, but also at the impacts on all health facilities (township health centers and county hospitals) in the counties. Our results are bad on a comparison of changes before and after the
program’s introduction between houholds and facilities covered by the program and tho not covered by it. We couple this double-difference or difference-in-differences approach with matching methods to reduce the possible bias due to the two groups having different pre-program characteristics that may influence both changes in outcomes after the program’s introduction and the houhold’s or facility’s coverage status. In our analysis of houholds, we look at impacts not only for the sample as a whole but also for lected income deciles, allowing us to explore possible differential impacts between poor houholds and others further up the income distribution.
The paper is organized as follows. Section II provides a brief description of the NCMS. Section III outlines our methods. Section IV prents our data. Section V prents the estimation results of the model we u to estimate the propensity score for our analysis of houhold impacts, and prents the results of our balancing tests. Section VI prents our estimates of the program’s impacts, and the final ction (VII) contains a summary and discussion.
II.THE NEW COOPERATIVE MEDICAL SCHEME8
NCMS differs from the old CMS in veral key respects. It is a voluntary scheme.9 However, to make it fairer and financially more attractive to low-risk houholds, contributions are supplemented queens
chken
by government subsidies. Another key difference between NCMS and the old CMS is that the new scheme is to operate at the county level rather than at the village or township level, thereby providing for a larger risk pool and for economies of scale in organization and management. 10 Counties are being given considerable discretion in the design of NCMS—the risks covered, the emphasis on inpatient and outpatient expens, the u of demand-side and supply-side cost-sharing, and so on. One reason for this was simply an acknowledgement that local choice on design issues is an integral feature of China’s highly韩语 我爱你>四年级上册英语
8 This ction draws on a county program survey that was done along with the houhold survey on which this paper is bad. More details about the survey are provided in the data ction below. For information about design and implementation of the NCMS, also e Mao (2005).
9 At least in part, this decision was motivated by widespread dissatisfaction in rural areas with a proliferation of fees and taxes. In order to reduce the tax and fee burden of rural residents, the government has eliminated a number of rural taxes and reduced others (Yep 2004; Lin 2005) (Tao and Liu 2005). In this context, it was en as difficult to introduce a new mandatory charge.
10 Most rural counties have a population ranging from 200,000 to 300,000 people.
decentralized health system. But there was also another reason—to ensure that lessons could be learnt from local experimentation, and that that they could be fed into the scaling-up process.杭州服装设计
To capture better the details of the scheme at local level, we administered a detailed program questionnaire in 17 NCMS counties.11 The program survey was complemented by a qualitative study (Wu et al. 2006), involving focus-group discussions and mi-structured interviews with NCMS stakeholders, including NCMS management, the local NCMS monitoring committee, health care providers at county and township level, village leaders, village doctors, and rural residents themlves.
The voluntary nature of NCMS rais concerns about adver lection. Participation rates in pilot counties are, however, for the most part high, with an average in excess of 80 percent (e descriptive information in Table 1). In part, high levels of participation are likely to be the result of features of the NCMS that are meant to address the problem of adver lection, notably the relatively generous government subsidies and the requirement that participation be at the houhold level. However, the qualitative study suggests that local governments have also exerted considerable efforts to achieve high levels of participation (Wu et al. 2006).
While central government has issued broad guidelines for how the NCMS should be designed and implemented, provincial and county governments retain considerable discretion over the details. One area of discretion concerns the placement of the program. NCMS pilot counties were not randomly lected. Rather, a complex t of criteria, including local interest and capacity, level of economic development, and the status of the delivery system were considered. The implications of lective program placement for our identification strategy are discusd in the methodology ction below.
Local government also has some discretion over the level of financing of the program, and the associated benefit package. Currently, the minimum requirement is a 10 RMB (per person) beneficiary contribution from houholds, supplemented by a subsidy of 20 RMB from local government (40 RMB in the ca of eastern provinces), and a 20 RMB matching subsidy from central government in the ca of houholds living in the poorer central and western
11 A short form of the program questionnaire was also administered to all other counties (N=162) with official NCMS pilots in
the 17 provinces covered by the survey. The data are not ud in the prent paper.
