I. The Governance Structure of China's Traditional Rural Cooperative Medical System
(1) The Origin and Evolution of the Traditional Cooperative Medical System
In the early years of the founding of the PRC, the severe domestic and foreign political and economic situation posed a great threat to national security, and out of the considerations of national defense and military affairs, the implementation of the over-advanced development strategy of heavy industry in imitation of the model of the former USSR became inevitable. However, our country's economic development level is low, the industrial base is weak, agricultural surplus products are the main raw capital of the country's industrialization, the country has and only through the industrial and agricultural products exchange scissors way from the rural areas to draw economic surplus to promote industrialization. Therefore, in order to promote industrialization in a comprehensive manner, urban barriers represented by the household registration system were established, and productive and living resources were stranded in the cities through the ticket system corresponding to the household registration; at the same time, the dual economic and social structure was further promoted, leading to a fundamental difference between urban and rural economic and social functioning mechanisms, and, in the context of a relatively short supply of resources, the orientation of industrialization, in particular, made it possible for the protection of the labor force in the industrial sector to become the the preferred goal and value orientation of the entire public *** policy. [2] The state adopted the principle of differentiated welfare provision for urban and rural areas in a targeted manner in the distribution of welfare, i.e., starting in the early 1950s, China gradually established a medical security system compatible with the planned economy, with publicly-funded medical care and labor-insurance medical benefits being provided by the state to urban publicly-owned units and institutions. And farmers who lacked medical insurance began to take the form of spontaneous mutual aid to solve the problem of lack of medical care in rural areas.
The formal emergence of a cooperative medical care system with mutual assistance in rural areas in China was the climax of the rural cooperative period in 1955, when a number of health care stations organized by rural production cooperatives appeared in the rural areas of Shanxi, Henan and other provinces, adopting a combination of "health care fees" and subsidies from production cooperatives to solve the problem of not being able to see a doctor. The problem of not being able to see a doctor was solved. This spontaneous form of mutual assistance was short-lived, because institutional change in any society actually involves the adjustment and distribution of interests. In the composition of multilateral power participation, influence and transaction, different social forces will be pulled into the arena of political order, and various dispersed interests will be organized and passed into the socio-political system in order to avoid the agglomeration of non-institutionalized forces outside the system. [3]Cockerham, through his study of health care systems in developed and developing countries, also shows that, whether it is a socialized health care system or a decentralized health care security system, governments actually exercise direct and indirect management and control over health care. [4]
In 1956, the Model Statutes of Higher Agricultural Production Cooperatives, adopted at the Third Session of the First National People's Congress, stipulated that the cooperatives should be responsible for the medical care of their members who were injured on duty or became ill on duty, and that they should give discretionary labor days as a subsidy, thus for the first time conferring on the collective the responsibility of intervening in the medical care of the members of the rural society for their illnesses. The government's action on the issue of rural health care in the communes was signaled by the Ministry of Health's report to the Central Committee of the People's Republic of China in November 1959, following the National Conference on Rural Health Work held in Jishan County, Shanxi Province, and its annex, "Opinions on a Few Issues Concerning the Health Work of People's Communes", which stated, "With regard to the people's communal health care system, there are at present two main forms. There are two forms of medical care system in the people's commune: one is that whoever sees a doctor pays for the care; the other is the implementation of a collective health care system for the members of the people's commune. According to the present level of development of the productive forces and the actual situation of the masses' consciousness, it is appropriate to implement the collective health care system for the members of the people's commune." In February 1960, the Central Committee of the People's Republic of China forwarded the report of the Ministry of Health and its annexes, which it considered to be "very good", and requested that they be implemented in all parts of the country with reference to the report. In February 1960, the Central Committee forwarded the Ministry of Health's report and its annexes, deeming them "very good" and requesting that they be implemented everywhere. Since then, cooperative medicine has become a basic system for the government to implement health care in China's rural areas.
In September 1965, the Central Committee of the People's Republic of China (PRC) approved the report of the Party Committee of the Ministry of Health (MOH) on "Putting the Focus of Health Work on Rural Areas," emphasizing the strengthening of primary health care in rural areas, which gave impetus to the development of the cooperative medical care system in rural areas. The cooperative medical system was fully implemented after 1966, during the Cultural Revolution, when Mao Zedong personally wholesaled the experience of the Paradise Commune in Changyang County, Hubei Province, and issued the directive "Cooperative medical care is good". In the political climate of the time, counties, communes and production brigades in the vast majority of rural areas set up medical and health institutions, forming a relatively complete three-tier preventive health-care network. By 1976, 90 percent of the country's farmers had participated in cooperative medical care. Subsequently, in 1978, the Constitution of the People's Republic of China, adopted by the Fifth National People's Congress, stipulated in Chapter III, Article 50, that "Workers have the right to material assistance in old age, sickness, or incapacity for labor"; and in 1979, in accordance with the Constitution and the actual situation at that time, the Ministries of Health, Agriculture, Finance, and Medicine, as well as the General Administration of the State Pharmaceutical Administration, jointly organized a cooperative medical care program for peasants. Constitution and the actual situation at the time, jointly issued the Rural Cooperative Medical Care Statute (Draft for Trial Implementation), in which Articles 1 and 2 stipulate the nature of rural cooperative medical care: "Rural cooperative medical care is a medical care system of a socialist nature established by the members of people's communes relying on collective strength and based on voluntary mutual assistance, and it is a collective welfare undertaking for the members of the commune ": "In accordance with the provisions of the Constitution, the State actively supports and develops cooperative medical care, so that medical care and health care can better serve the protection of the health of members of people's communes and the development of agricultural production. For societies with economic difficulties, the State provides the necessary support." [5]
From the above analysis of the origin and evolution of the cooperative medical system, we see that, in the early years of the founding of the country, although the state did not extend the urban medical insurance system to the countryside, but also did not leave it unattended, but actively intervened in the establishment of the rural medical system from the outside to establish a rural cooperative medical system into the national economic and social system, but limited to the country's financial resources at that time, the rural medical cooperative adopted a "cooperative medical care system", which was "a system for the rural community to protect the health of the members of the people's commune". However, due to the limited financial resources of the country at that time, the cooperative medical care has adopted the development path of "community-run national rural medical system".
(2) The governance structure of the traditional rural cooperative medical system
Since China's rural cooperative medical system is a special institutional arrangement formed under a specific historical period, it has its own unique form of expression compared with foreign social welfare systems, and in terms of its governance structure, it has formed a "cabbage" structure in which the publicly funded structure is externalized and the privately funded structure is internalized. "Structure:
The externalization of the publicly-funded structure, i.e., the government's control and monopoly of medical services and the supply of medical resources, plays a supportive role for cooperative medical care. It mainly includes: (1) the state owns all medical institutions, neither private health insurance companies nor private medical practitioners, the government uses its capital accumulation advantage to rapidly establish a rural health network including medical institutions of communes and production brigades with county hospitals as the leader, and the government controls all the channels of medical service supply. (2) The government controlled all channels of medicine and controlled the prices of medicines; (3) The government was responsible for funding the prevention of endemic diseases; and (4) The government was responsible for training rural doctors.
The internalization of the privately-run structure, that is, the government has no financial allocations for rural grass-roots health institutions, mainly relying on the production team's public welfare fund withdrawals, farmers pay health care fees to ensure the source of funding, to achieve the "joint medical care, prevention and non-prescription of drugs," the pre-payment of community health care model. It mainly includes: (1) farmers participating in rural cooperative medical care are required to pay a certain amount of health care fees; (2) the rural cooperative medical care fund mainly comes from the collective economy, originating from the public welfare fund of the collective economy; (3) the labor remuneration of doctors and health personnel is paid by the collective economy; (4) the operation of the commune health center mainly relies on the support of the community team's finances, while the brigade health office relies on the collective economy to maintain the health room's house and instruments invested by the brigade, and the mobile health office is maintained by the brigade's financial support. instruments are invested by the brigade, and working capital and personnel funds are mainly allocated by the production team; (5) in terms of management, the implementation of village-run village management, village-run township management, village-run township management, township-run township management and so on.
From the perspective of governance structure, the strength of the publicly-funded structure depends on the strength of control over medical services, medical resource supply and other aspects and the size of the identity of political authority to govern. The level of privately-run is directly related to the strength of the collective economy and the amount of income of farmers. And whether the governance structure of any kind of medical system is effective depends on whether it can resolve the three major problems of supply-side induced demand [6], adverse selection [7] and moral hazard [8], and in the rural areas, it is also necessary to solve the problem of accessibility and availability of health care services, which the traditional cooperative medical system has resolved to a certain extent:
(1) In the problem of supply-side induced demand, although the traditional cooperative medical care supply-side medical service institutions are the monopolists and price-setters of medical services, the labor remuneration of doctors and health personnel is paid by the collective economy; the operation of communal health centers relies mainly on the support of community finances, while brigade health offices are sustained by the collective economy; the houses and instruments of the health offices are invested by the brigades; and the liquidity and personnel funds are mainly allocated by the production brigades. In other words, whether it is barefoot doctors (part-time rural health workers), commune health workers, or medical staff of county-level and above medical institutions, their incomes are set by the collectives or the state, and the income and benefits of medical service organizations and service workers are not related to the supply of medical services, and there is no incentive mechanism for providing excessive services. This inhibits supply-side induced demand to a certain extent.
(2) On the issue of adverse selection, although the traditional cooperative medical care emphasized the voluntary principle, the implementation of universal control of the rural grassroots organization dissolved the problem of adverse selection. At that time, the high political importance and strong political mobilization gave cooperative medical care strong external support, the people's commune, as a grass-roots social organization, fully grasped the power of politics, economy, culture and other powers in the area under its jurisdiction, and any individual farmer could not exist independently from the commune, and there was no way to choose at all, either in the reverse or in the positive direction. [9]
(3) On the issue of moral hazard, under the planned system, the quantity, quality, and price of medicines, etc., were rationed, and the behavior of drug dealers had no effect on the cooperative medical system; similarly, hospitals, being public, did not make a profit or generate income, and were an extraneous variable to farmers' health insurance. That is, a low-cost medical delivery (supply) system in a planned economy can be effectively integrated with cooperative medicine, where the government controls the power to allocate resources for medical services and medicines and implements a low-cost supply strategy; drug prices are also controlled by the state program and kept at a low level. In the absence of incentives for high prices and high rewards, barefoot doctors, as well as health care providers at all levels, are well protected from moral hazard.
(4) On the issue of accessibility and availability of medical services in rural areas,[10] for one thing, the government has emphasized the use of herbal medicines and techniques of traditional Chinese medicine through the restoration and revitalization of traditional Chinese medicine, which has reduced the expenditures on the funding of the cooperative medical care and alleviated the burden of the peasants due to the large amount of inexpensive Chinese herbal medicines and homemade medicines that have enriched the sanitary clinics and the local pharmacy; and for the other thing, the government, through the training of the barefoot doctors, has managed to "Early treatment of illnesses, early prevention of diseases", "small illnesses do not go out of the group, big illnesses do not go out of the village".
From the above analysis, we find that there are two important foundations for community-based financing and organization of rural cooperative health care: first, the cooperative health care system is embedded in the social structure and is institutionalized, the externalization of the public assistance structure is the framework for the operation of the cooperative health care, and the political authority is the mechanism of its governance; and second, the mutual assistance of the members as well as the cooperative self-organization and the organization of the community team is a natural overlap.
The deconstruction of the traditional cooperative medical system in the transition period
With the economic and social transformation, the development of the cooperative medical system has been subjected to an unprecedented impact and is rapidly declining, for a variety of reasons:
(1) With the reform of the rural contract responsibility system, the establishment of a hierarchical management of the financial system, so that the financing of the cooperative medical fund is facing a crisis. Rural cooperative medical care in the "cooperation", refers to the cooperation between farmers and collective and individual cooperation, and has always been a collective contribution to the cooperation of the "big shares", individual farmers only pay a small part. Such "cooperation" was not a problem during the cooperativeization of agriculture and the "three withdrawals and five unifications", because the individual portion was withheld by the collective and the collective had sufficient economic resources to pay for the collective portion of the burden. After the implementation of the "fee to tax" in rural areas, the collective has no right or opportunity to withhold the cooperative medical fee, and the individual part can only be collected at the doorstep, coupled with the current high mobility of the rural population, this part of the collection to the account of the obvious problems; there are also many economically weak areas in the "fee to tax" after the "fee to tax" has become the "fee to tax". After the "fee to tax" has become "eat financial", many villages and groups even have debts, according to the ability to participate in the "cooperation" without funding; at the same time, the restructuring of township enterprises, exacerbated the substantial decline in the accumulation of the public ****, there are At the same time, the restructuring of township and village enterprises aggravated the substantial decline in public ****accumulation, making it difficult to raise funds for the cooperative medical fund, and so on; these problems caused the grass-roots cooperative medical organizations to become a mere formality or to disintegrate of their own accord, and led to the emergence of problems such as the inability to maintain collective cooperative medical care, the contracting of individual village doctors and the opening of private practices, and the difficulty of implementing preventive health care in rural areas. By 1998, when the second national survey of health services, 87.4% of China's farmers have been completely self-funded health care [11].
(2) In the context of market transformation, the most central feature of China's health care reform is that almost all health care providers have transformed from public institutions, which relied almost exclusively on governmental financial allocations, to service-for-income organizations, even public ****health institutions (e.g., epidemic prevention stations). In rural areas, the medical service delivery system has shown a trend of privatization; according to statistics, by 1998, about 50% or so of the country's village health and sanitation offices had been turned into individual medical outlets,[12] and there are still some offices that are formally contracted out to sanitarians but are essentially indistinguishable from individual medical outlets due to the abandonment of their management by the village committees; at the same time, in the context of the marketization of the supply of medicines, the government's supervision of the drug At the same time, under the marketization of medicine supply, the government's management and supervision of the sales chain is ineffective. In this case, facing the market is the inevitable choice of township health centers, but the medical market is not completely liberalized, the formation of individuals contracted along the rural health network (township and village health centers), the monopoly of the rural health care market, so that the rural health care market substitutability is very low, whether privately-run or publicly-run, and all the health service providers charge the patients on a per-item payment basis. Following changes in the incentive structure, the problem of supply-side induced overconsumption has also emerged in the rural healthcare sector, where health organizations and health practitioners at all levels no longer have the incentive to proactively reduce the cost of medicines. Increasing market orientation inevitably leads to one of the most classic problems in health care: supply-induced overconsumption. In the countryside, all health care providers accessible to farmers, such as county hospitals, township health centers, maternal and child health care facilities, epidemic prevention facilities, and village health clinics, have been prompted to abuse their prescribing power in pursuit of their own incomes, thereby inducing overconsumption by patients and leading to rising health care costs, as health care providers rely heavily on fees for their operations.
(3) In our survey of rural areas in southern Jiangsu, we found that the original cooperative medical system only aimed at solving the problem of lack of medical care in rural areas, and advocated "a needle and a handful of grass," which was a low target. In today's more affluent rural medical consumption structure, there are both basic survival consumption and health care, enjoyable consumption; both the need to prevent and treat diseases, but also the pursuit of comfort and quality service expectations; both the pursuit of nourishing health and the desire to solve the risk of serious illness. In the survey, we also found that after the national life expectancy has been extended, some non-communicable "old people's diseases", such as cancer, diabetes, stroke and heart disease, have replaced communicable diseases in rural areas, playing the role of people's "health killer". The difficulty (or impossibility) of preventing these diseases and the high cost of treating them have made relatively low-cost public health policies, which were effective in the fight against infectious diseases in the early 20th century, irrelevant. The bottom line is that the low-cost public ****care policies of the past are no longer effective in the face of these diseases that require expensive drug treatments. [13]
Third, the governance structure of the new rural cooperative medical system
Social welfare as a right of citizens is a concept proposed and widely spread by T.H. Marashall ) after World War II. And the most important function of the government should be to undertake the responsibility of ensuring the welfare of the people. From the perspective of welfare philosophy, health care is more of an opportunity, and quality health care should be a right available to all people, regardless of their living conditions or economic status. From the point of view of the practice of worldwide action, health care has become a part of the right to life, and each country, due to its national conditions or different national strengths, does not fail to assume more or less responsibility for the health care of its nationals, and to support the operation of the health care system by the public *** finance, health care services should obviously be categorized into the scope of the public *** goods. If the principle of separating the social security systems of urban and rural areas and treating urban and rural residents differently in terms of security was implemented as a last resort under the conditions of extreme financial constraints in the early stages of China's industrialization, today, in the midst of a widening gap between urban and rural incomes, serious inequities in the distribution of urban and rural health-care resources, and a high rate of out-of-pocket medical expenses by peasants, and with the country's financial strength constantly growing, how does the government in the rural cooperative health-care The problem of "in place" has become very prominent.
In January 2003, the General Office of the State Council forwarded the Ministry of Health and other departments "on the establishment of a new type of rural cooperative medical system opinions" (hereinafter referred to as "opinions"), in the "opinions", stressed that "the new type of rural cooperative medical care is a kind of governmental organization and guidance, to the main disease co-ordination of farmers' medical care and mutual assistance ****ji system ". That is, the government seeks to rebuild the cooperative medical system, the original community medical system into the main system of national rural medical security, chose the "national rural medical system community office" development path.
According to the relevant provisions of the new cooperative medical care system and the pilot situation in various regions, the new cooperative medical care system has made substantial changes compared with the traditional cooperative medical care system:
(1) The change from the "public assistance" of the traditional cooperative medical care system to the "public office" of the new cooperative medical care system has been manifested in the following ways. Publicly run", manifested in: First, compared with the traditional cooperative medical care emphasizing only individual and collective **** with the financing, the new rural cooperative medical care, the most important feature of the government's responsibility is clearly defined, through the central tax financing, transfer payments, as well as the local government's fund-raising, the central and western regions and underdeveloped areas of cooperative medical care to give the investment. To this end, the new type of cooperative medical care proposes "the implementation of a financing mechanism that combines individual farmer contributions, collective support and government funding." And in the Opinions of the specific provisions: "local financial subsidies to participate in the new type of cooperative medical care for farmers not less than 10 yuan per capita per year. Specific subsidy standards are to be determined by the people's governments at the provincial level. From 2003 onwards, the central financial authorities will arrange cooperative medical care subsidies of 10 yuan per capita per year for farmers participating in new cooperative medical care in central and western regions other than urban areas," marking the beginning of new cooperative medical care with the nature of cooperative insurance. Particularly in impoverished areas, government financing has taken a major role. Secondly, in terms of the management system, it is clear that the county (city) is the unit of co-ordination. Even those who were coordinated by townships at the initial stage are to "gradually transition to county (city) coordination". This is different from the traditional cooperative medical care system of "village-run and village-managed", "village-run and township-managed", and "village-run and township-managed" management and coordination. At the same time, the new type of cooperative medical care has also established top-down coordinating committees, county management agencies and supervisory bodies in accordance with a unified model, and set up a special rural cooperative medical care management agency within the health administrative department, constituting a pattern of full government participation.
(2) In terms of governance structure, the traditional cooperative medical system has changed from a "private-public" governance structure to a new type of cooperative medical system with a "citizens' cooperative" governance structure. The traditional cooperative medical system's "privately-run-publicly-assisted" governance structure is relatively easy for people to understand and grasp, while the new cooperative medical system's "citizen-run" governance structure is difficult to understand and operate in practice, and existing research is also concerned about the inner workings of this governance structure. The existing research is not enough to explore the connotation of this governance structure.
In our opinion, the governance structure of "Citizens' Co-operation" is not only a choice based on national conditions, but also in line with the development trend of social policies. In the process of governance of welfare diseases in western countries, the most striking thing is the rise of "welfare pluralism" (welfare pluralism). On the one hand, welfare pluralism emphasizes that welfare services can be provided by four sectors, namely, the public sector, profit-making organizations, non-profit organizations, and the family and the community, and that the role of the government has gradually shifted to that of a regulator of welfare services, a purchaser of welfare services, and an arbiter of the management of goods, as well as a facilitator of the role of the other sectors in the provision of services. On the other hand, the participation of non-profit organizations is emphasized to fill the vacuum left by the government's retreat from the welfare field and to ward off the overstretching of market forces, and, at the same time, to achieve the functions of integrating welfare services, promoting the efficiency of welfare provision, and rapidly meeting changes in welfare needs through non-profit organizations. The two main concepts of welfare pluralism are decentralization and participation. The so-called decentralization is not only the transfer of the administrative power of welfare services from the central government to the local governments, but also the transfer from the local governments to the communities, and the transfer from the public *** sector to the private sector. The essence of participation is that non-governmental organizations can be involved in the provision or planning of welfare services, and welfare consumers can participate in decision-making alongside welfare providers***. [14] So, in this sense, the government in rural cooperative medical care not only have "in place" problem, but also to solve the "positioning" problem.
Citizen co-production, on the one hand, can be said to be the government's role in the repositioning. On the other hand, the government and civil society organizations to form a subtle cooperative relationship. [15] That is, through the government's cooperation with collective economic organizations, local community organizations, and health care organizations, etc., to *** with the production, delivery of health care services, so as to enhance the effectiveness. Of these two aspects, the key one is the understanding of governance, which Friedrichsen insightfully articulates by arguing that the original equilibrium between the state and society has shifted, and that nowadays the public *** sector, the private sector, and the quasi-public *** sector are situated in a networked environment where the vertical and the horizontal are intertwined, and that this new interaction represents a sharing of responsibilities and tasks and a collaboration between the public *** sector and the private sector. This new form of public-private synergistic interaction is called "governance". [In this sense, the government cannot just use orders as a means of governance, but it must use new tools and techniques to deal with navigation and guidance, emphasizing the role of the national government as a navigator. [17]
Through the above discussion, it can be seen that: the government is the formulator and supervisor of the new cooperative medical care policy, as well as one of the main subjects of implementation, and farmers are not only the main subjects of contribution and benefit, but also one of the main subjects of supervision and implementation. At present, in the new type of cooperative medical care, the phenomenon of large-scale government intervention replacing the previous self-governance mechanism within villages and communities and the system of collective provision of health services has appeared; there has been a tendency for the government not only to manage planning and financing, but also to directly manage the operation and supervision of the program, and to wear several hats, and the role of farmers has evolved to become a fee-paying participant of the entire cooperative medical care system, which is in contrast to the new type of cooperative medical care, in which the government is the main body to formulate and supervise the policy of "citizen co-operation. "This is contrary to the governance structure of the new cooperative medical care system. The governance structure of the new cooperative medical care "citizen co-operation" may still need to be developed and improved in practice, but there are several outstanding issues that need to be discussed and resolved:
(1) What kind of governance mechanism should be used to resolve the problem of adverse selection? The new cooperative medical system in the implementation process, due to the implementation of the principle of voluntariness, the biggest problem it faces is the problem of adverse selection. Obviously, the old, the weak, the sick and the disabled are naturally willing to participate in cooperative medical care because they have a higher chance of benefiting from it. However, their incomes are usually low and their ability to pay is limited. The young and healthy have higher incomes and greater ability to pay, but they are less likely to benefit and therefore less willing to participate. The result of free choice is that a large number of healthy people are unwilling to participate, and most of the participants are weak and sick, and even in practice, "many families only pay for the old and infirm in the family to participate in the cooperative medical care". [As rational human beings, farmers are most concerned about whether they can benefit from the new cooperative medical care, and whether the new cooperative medical care policy, which focuses on major illnesses, can bring benefits to them. From the current situation, the rate of major diseases among the contributing farmers is extremely low, according to statistics, the hospitalization for major diseases only accounts for 1-3% of the population. [19] The new cooperative medical system means that the vast majority of contributing farmers do not receive any benefits, and it is not attractive to them. In order for cooperative medicine to be sustainable, maintaining a high coverage rate is necessary, and to maintain a high coverage rate, where it is not possible to increase its attractiveness, the implementation of mandatory governance mechanisms is the only way to defuse adverse selection.
(2) What kind of governance mechanism is used to defuse the problem of supply-side induced demand and the problem of moral hazard? Under market economy conditions, supply-side induced demand is fully manifested in the medical service market, while the moral hazard problem is equally serious. In the face of these health insurance problems, first of all, we can set up a tripartite rural medical cooperative composed of the grassroots government, farmers' organizations and medical institutions, so as to fundamentally enhance the negotiating power of farmers in the medical service market, so that when purchasing health care services, the combination of prevention and treatment, major and minor illnesses, and the set of programs mainly based on mutual insurance proposed by the rural medical cooperative can be realized with the financial subsidies and policy support of the government. With the government's financial subsidies and policy support, it will be possible to purchase a full set of services from medical institutions as a whole, so that cooperative medical management organizations can fully represent the interests of the insured in their negotiations with medical service providers and strive for the greatest benefits for those who participate in cooperative medical care, realizing the use of the demand strategy to change the supply-side-induced demand pattern of the current cooperative medical care in rural areas. Second, while the government dominates the rural primary medical service market by running non-profit county-level medical institutions, it is also liberalizing the rural medical service market, increasing the substitutability of the rural medical service market, and suppressing moral hazard by means of the competition mechanism. Finally, in the cooperative medical management system, we can explore the implementation of "levy, management and supervision" system, so that the fund levy management, business management and supervision and management by the corresponding subject to undertake, so as to improve the performance of management.
Fourth, conclusions and recommendations
With the economic and social transformation, the background of the cooperative medical care has undergone profound changes, the reconstruction of cooperative medical care is at a crossroads, and the new rural cooperative medical care system is currently developing in exploration. From the viewpoint of governance structure, "Citizens' Cooperative Office" is an effective choice in the market economy, but how to determine the governance mechanism and development direction has become the most critical issue, based on the above analysis, we have the following suggestions:
(1) It is recommended to implement a mandatory cooperative medical system to control the adverse selection, to ensure that The cooperative medical fund is mobilized, so that the cooperative medical care can be developed in a sustainable way. On the financing of the new cooperative medical care, the policy obstacles over the years have been eliminated, and the Opinion stipulates that "farmers' fulfillment of the obligation to pay fees for the purpose of participating in cooperative medical care and resisting the risk of disease cannot be regarded as an increase in the burden on farmers." The new type of cooperative medical care already has the characteristics of social medical insurance, but the farmers participate in the new type of cooperative medical care is still a voluntary way, in the market economy conditions, increasing the possibility of adverse selection; increase the collection cost of raising the cost of individual cooperative medical insurance, so the implementation of the mandatory cooperative medical care system should be one of the main elements of the governance of the new type of cooperative medical care system. In the specific operation process, the standard of financing can be designed with multiple programs and different corresponding treatment for farmers to choose. In terms of the object of protection, it can be a household, or a natural village and so on.
(2) Encourage farmers to establish medical cooperative organizations at the grassroots level, through the establishment of farmers' self-governing mutual medical management organization, guiding the farmers' representatives to participate in the management and use of funds, in order to obtain the farmers' trust to strengthen the sustainability of the cooperative medical care; the introduction of social and professional forces to help the farmers' medical co-operation body to put forward the combination of prevention and treatment, large (disease) and small (disease) combination of the main sets of mutual insurance. The introduction of social professional forces to help farmers' medical cooperatives propose a package of programs that combines prevention and treatment of major and minor illnesses, with mutual aid insurance as the mainstay, and to purchase the full range of services from the medical institutions with government subsidies and policy support, so that the cooperative medical management organization can adequately represent the interests of the insured in negotiating with the medical service providers, for example, on the wage level of rural doctors and the unit price of medical services, and so forth. Therefore, the establishment of an independent organization managed by the farmers themselves is to enable the farmers to benefit from the system and consciously and voluntarily maintain its sustainable development.
(3) Introducing a third-party management model, i.e., introducing a commercial insurance organization to be responsible for the financing and operation and management of the medical fund. In accordance with the principle of "collection, management and supervision", the government is responsible for the collection and management of the fund, the insurance company is responsible for business management, and the health administrative department is responsible for the supervision and management of the co-op form. By entrusting the management of cooperative medical services to commercial insurance companies, it is conducive to lowering management costs and improving operational efficiency; at the same time, the transparent and professional operation of commercial insurance company management can also be utilized to increase farmers' confidence in cooperative medical services. This form has been explored for many years in 14 counties (cities and counties), including Jiangyin City in Wuxi and Wujin in Changzhou, and has been relatively successful. [20] And only in this way can the government's strengths be brought into play and a fundamental change in its role be realized.
(4) While dominating the rural primary medical service market, enhance the rural medical service market alternative, through the possibility of market multi-choice to realize the governance of medical service prices, medical service irregularities. We suggest adjusting township health organizations and allowing township health centers to operate in the market, in which the adjustment of township health organizations should be mutually conditional with the adjustment of county-level medical institutions. As the pillar or "platform" of the rural health care network, the government should concentrate its efforts and financial resources on running non-profit county-level medical institutions. Under the condition of stabilizing county-level medical institutions, township health institutions should be liberalized. Township health centers should be allowed to separate medical care and prevention. In areas where the economy and transportation are relatively well-developed, after preserving preventive health care, some health centers should be merged or abolished in the light of specific circumstances. Most township health centers can be fully liberalized, and township health centers are encouraged to explore the reform of the property rights system and the adjustment of their mode of operation. Urban medical institutions are encouraged to reorganize or chain together township-level health resources, social groups and individuals are encouraged to purchase inefficiently operated health centers, to revitalize and activate unused health resources, a portion of township health centers are encouraged to turn into for-profit medical institutions, and revitalized assets are used for public **** health in rural communities, and enterprises, groups, and individuals, in accordance with the relevant conditions, are encouraged to set up health institutions at the rural township level .
(5) In the above discussion of the governance structure of the new rural cooperative medical system, the issue of accessibility and availability of the new cooperative medical care has not yet been addressed. This problem is also more prominent at present. It is mainly reflected in the following: in poor rural areas, the economic income of farmers is low and unstable, if there is no external financing assistance, the cooperative medical care in poor areas will have two characteristics, either very limited funds make it difficult to establish the cooperative medical care, or it is difficult to consolidate the cooperative medical care already established in terms of financing. [21] And in affluent areas, cooperative medicine cannot meet the needs of the affluent for multi-level and multi-faceted health care. Therefore, we believe that in poor rural areas, where the economic basis of cooperative medical care is weak, medical assistance should be implemented for the poor, i.e., the state should provide poor farmers with assistance for serious illnesses on top of providing basic medical care free of charge. The central and local governments should be responsible for the vast majority of the costs of the program***. In rural subsistence areas, a new type of cooperative medical care should be introduced for the subsistence population. In affluent rural areas, for the affluent population, according to their actual needs, while exploring the rural medical insurance system, to promote the establishment of urban and rural integration of the medical security system.
About the author: Lin Mingang, born in 1967, PhD in sociology, professor of the Department of Sociology, Nanjing University
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