The role of health system governance in strengthening the rural health insurance system in China

Abstract

BackgroundSystems of governance play a key role in the operation and performance of health systems. In the past six decades, China has made great advances in strengthening its health system, most notably in establishing a health insurance system that enables residents of rural areas to achieve access to essential services. Although there have been several studies of rural health insurance schemes, these have focused on coverage and service utilization, while much less attention has been given to the role of governance in designing and implementing these schemes.MethodsInformation from publications and policy documents relevant to the development of two rural health insurance policies in China was obtained, analysed, and synthesise. 92 documents on CMS (Cooperative Medical Scheme) or NCMS (New Rural Cooperative Medical Scheme) from four databases searched were included. Data extraction and synthesis of the information were guided by a framework that drew on that developed by the WHO to describe health system governance and leadership.ResultsWe identified a series of governance practices that were supportive of progress, including the prioritisation by the central government of health system development and certain health policies within overall national development; strong government commitment combined with a hierarchal administrative system; clear policy goals coupled with the ability for local government to adopt policy measures that take account of local conditions; and the accumulation and use of the evidence generated from local practices. However these good practices were not seen in all governance domains. For example, poor collaboration between different government departments was shown to be a considerable challenge that undermined the operation of the insurance schemes.ConclusionsChina’s success in achieving scale up of CMS and NCMS has attracted considerable interest in many low and middle income countries (LMICs), especially with regard to the schemes’ designs, coverage, and funding mechanisms. However, this study demonstrates that health systems governance may be critical to enable the development and operation of such schemes. Given that many LMICs are expanding health financing system to cover populations in rural areas or the informal sectors, we argue that strengthening specific practices in each governance domain could inform the adaptation of these schemes to other settings.

Scaling-up strategic purchasing: analysis of health system governance imperatives for strategic purchasing in a free maternal and child healthcare programme in Enugu State, Nigeria

“…The findings of this study that no clear framework for accrediting, contracting and monitoring providers exists is similar to absence of accreditation of health facilities in the federal free healthcare policy in Nigeria and limited mandatory accreditation of providers in Mexico’s Seguro Popular but contrasts the regular hospital accreditation and formal contracting of providers in Thailand’s universal coverage scheme (UCS) and China’s NCMS [8, 9, 12, 14, 15]. The purchasing agency, as a strategic purchaser, should select primary care providers and referral hospitals, which could be public or private, with explicit performance contract between the purchaser and providers indicating the selection criteria, service entitlements, provider payment system and routine performance monitoring system [4].…”

“…Sadly, the evidence of tax payment policy resulted in effective return of user fees in many health facilities, increasing the likelihood that the poor may not be protected from financial catastrophe. Residence-based entitlement could be adopted, in which pregnant women and under-5 children enrol with the network of primary health care providers within their localities as with experiences in Thailand, Mexico and China [8, 9, 14]. To register with providers, eligible beneficiaries may require proofs of residency such as certification letter by health facilities committee members, town union leaders or traditional rulers; or public utility bills consistent with experiences in Thailand’s UCS [8, 31].…”

“…Purchaser-provider split, described as assigning the purchasing and provision of healthcare services to separate organisations [3], was achieved in user fee removal schemes in Thailand, India, Vietnam and Nigeria [8–12], but undermined in Mexico, where the State Ministries of Health usurped purchasing function assigned to the State Health Social Protection Regime (REPSS) [13]. In China’s New Cooperative Rural Medical Scheme (NCMS), local government had autonomy to implement the scheme, determine the level of subsidy, the extent of benefit package and the co-payment stewardship, whereas the stewardship and fund management were assigned to the coordinating team and fund management committee respectively [14]. …”

“…Stakeholder participation and transparency in the benefit package design in tax-funded fee exemption schemes were high in Thailand and Mexico, but low in Vietnam, India, Nigeria and China [10–12, 14, 15]. Health technology assessment (HTA) informed the benefit design in Thailand and Mexico, but not in India and Nigeria [11, 12, 15, 16].…”

“…Health technology assessment (HTA) informed the benefit design in Thailand and Mexico, but not in India and Nigeria [11, 12, 15, 16]. Provider accreditation, has been used to contract providers, monitor and improve quality of care in tax-funded fee exemption schemes in Thailand and China [4, 8, 14, 15], but is limited in scope and transparency in Mexico’s Seguro Popular [9] and totally absent in a free healthcare policy in Nigeria [12]. …”