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Prescribing Behaviour of Village Doctors Under China•S New Social Science & Medicine 68 (2009) 1775–1779 Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed Prescribing behaviour of village doctors under China’s New Cooperative Medical Schemeq Xiaoyun Sun a,*, Sukhan Jackson b, Gordon A. Carmichael c, Adrian C. Sleigh c a Health Department of Shandong Province, Division of Maternal & Child Health and Community Health, 9 Yan Dong Xin Road, Jinan, Shandong 250014, China b School of Economics, The University of Queensland, St Lucia, Brisbane, Queensland 4072, Australia c National Centre for Epidemiology and Population Health, The Australian National University, Canberra, ACT 0200, Australia article info abstract Article history: In 2003, China introduced a new community-based rural health insurance called the New Cooperative Available online 1 April 2009 Medical Scheme (NCMS). In 2005, to assess the NCMS effects on village doctors’ prescribing behaviour, we compared an NCMS county and a non-NCMS county in Shandong Province. We collected information Keywords: from a representative total of 2271 patient visits in 30 village health stations (15 per county). China The average number of drugs prescribed (4.6 in the NCMS county vs. 3.1 in the non-NCMS county) and Village doctor use of antibiotics (72.4% vs. 59.3%) and injections (65.1% vs. 56.3%) were high in both counties, and higher New Cooperative Medical Scheme in the NCMS county. Within NCMS villages, prescribing for insured vs. uninsured patients showed Prescribing behaviour Antibiotics a similar pattern with more drugs, antibiotics and injections for those insured. Overall, for NCMS Health insurance patients, the prescription excess was about equal in value to their 20% fee discount. Rural We conclude that over-prescribing is common in villages and worse with NCMS health insurance, raising concerns for health service quality and drug-use safety. We propose that the NCMS should be redesigned with incentives for service quality improvement. A stricter regulatory environment for doctors’ prescriptions is needed in rural China to counter irrational drug use. Ó 2009 Elsevier Ltd. All rights reserved. Introduction providers (Liu, 2004; Meng, Liu, & Shi, 2000). Government spending fell from 36.2% of total health expenditure in 1980 to In 2003, the Chinese government launched a New Cooperative 15.2% in 2002 (Centre for Health Statistics and Information Ministry Medical Scheme (NCMS) to help finance rural healthcare. The of Health, 2004). Farmers are not eligible for the national basic NCMS began in 305 pilot counties and is expected to cover all rural medical insurance scheme for urban employees set up in 1998. areas by 2010. Such health insurance is designed to reduce cata- Now most rural residents pay out-of-pocket for medical care which strophic medical payments (Sun, Jackson, Carmichael, & Sleigh, is provided on a fee-for-service basis. 2009) but it could also encourage opportunistic behaviour from In 1994, the Chinese government piloted a rural community- healthcare providers, such as over-prescribing drugs. Here we based medical scheme, pooling risk for a township of 10,000– compare drug prescribing in village health stations in areas with 50,000 people. Many of these early insurance schemes closed down and without the NCMS. due to inadequate funding and dwindling political interest, Current reforms of the rural health finance in China are related although some survived to the new millennium (Jackson, Sleigh, Li, to other economic reforms in China over the last 25 years. The & Liu, 2005). But interest in rural health financing continues in abolition of agricultural communes in 1982 led to collapse of China and the NCMS was introduced with important changes. The community-funded healthcare for farmers. Market-oriented health new insurance scheme draws from the larger population pool sector reforms followed with privatization of rural healthcare (200,000–1 million) of a whole county and is supported by financial commitments from several levels of government (Dummer & Cook, 2007; Sun et al., 2009). q The Ford Foundation International Fellowship Program supported Xiaoyun Sun One question confronting Chinese policy makers is the effect the for her PhD study; the National Centre for Epidemiology and Population Health of NCMS has on healthcare providers. Earlier works (Dong, Bogg, the Australian National University, and an Australian Research Council Large Rehnberg, & Diwan, 1999; Dong, Bogg, Wang, Rehnberg, & Diwan, Research Grant (No. A00105533), added support for field work. * Corresponding author. Tel.: þ86 13553180219; fax: þ86 531 67876166. 1999; Zhang, Feng, Zhang, & Zhang, 2003) reported an association E-mail address: [email protected] (X. Sun). between health insurance and over-prescription in rural China. The 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.02.043 1776 X. Sun et al. / Social Science & Medicine 68 (2009) 1775–1779 studies were conducted before the introduction of the NCMS and (1) the number of drugs prescribed per patient visit; were mostly concerned with township hospitals. Our study takes (2) whether the prescription included antibiotics; place after the NCMS began and focuses on prescribing behaviour in (3) the method of drug administration (oral/external or injection); village health stations, the level of care below township hospitals. (4) total medical costs per patient visit. Village health stations are the most easily accessed by farmers and there is at least one in every village. We collected first-hand We compared these indicators between NCMS and non-NCMS information in 2005 from a sample of 30 village health stations in village health stations to reflect differences in prescribing behav- Shandong Province, comparing Linyi county (with NCMS) and Qihe iour. Within NCMS villages in Linyi, NCMS members and non-NCMS county (without NCMS). We are unaware of previous reports on members were compared to reflect the difference in prescribing effects of the new medical scheme comparing a county with and behaviour for the insured and uninsured. All data were analyzed without an NCMS. using SPSS version 12. Methods Results Study setting Background of the NCMS in Linyi county Linyi (with NCMS) is a typical agricultural county in Shandong The NCMS in Linyi began in 2003 with coverage of 93.5% and with a total population of 519,300 with 81% as farmers. The average rose to 94.6% in 2004. Per capita funding of the NCMS was 23 yuan net income of farmers was 3031 yuan in 2003 (Bureau of Statistics (10 yuan from the individual and a total of 13 yuan from various of Linyi County, 2004). In 2003, the infant mortality rate was 12.91 levels of government). Of the total available NCMS funds, 70% were per 1000 live births and the maternal mortality ratio was 37.4 per allocated to inpatient reimbursements and 30% to outpatient 100,000 live births. services delivered by township hospitals or village doctors. The Qihe county (non-NCMS) was selected for similar geographical, NCMS has contractual agreements with various health facilities cultural, socio-economic conditions, and healthcare policy and (e.g. village health stations) relating to the payment system and the regulation (including drug policy and administrative strategies), delivery of health services. but no NCMS operated in it. The total population was 609,100 and NCMS benefits cover pharmaceuticals, outpatient services in 83.9% were farmers. The average net income of farmers was 3028 village health stations, outpatients and inpatients in township yuan in 2003 (Bureau of Statistics of Qihe County, 2003). The infant hospitals and in county or higher level hospitals. Patients at village mortality rate and maternal mortality ratio were 13.89 per 1000 health stations receive a 20% discount for medical expenses during live births and 37.5 per 100,000 live births. each visit, and village doctors keep a record of discounts given which are then inspected by NCMS officials. The NCMS pays village health stations an annual capitation of 3 yuan per insured villager. Sampling of village health stations Capitation payments account for about half the NCMS funds allo- cated for outpatient services with the rest going to township A total of 30 village health stations (VHSs) were selected hospitals. Hospital outpatients also directly pay for medical through stratified sampling. All townships in both study counties services at prices discounted at 20%. Inpatients receive 20–75% were already divided by local officials into three tiers of socio- reimbursement for medical expenses, higher reimbursement rates economic status (SES): high SES, middle SES and low SES town- for higher expenses; there is a ceiling of 20,000 yuan per person per ships. In both counties, one township was randomly selected from year. each of the three SES strata. From each of the six selected townships five villages were randomly chosen. All village health stations in the Description of NCMS and non-NCMS patients at 30 village health 30 chosen villages were investigated; the total number of village stations health stations sampled was 30 because each village had only one village health station. The study was formally approved by the In 2005, we recorded 2271 patient visits in two weeks at the 30 Ethics Committee of the Australian National University, Canberra. village health stations: 1025 at NCMS and 1246 at non-NCMS VHSs. In addition, the field research was approved by the Provincial New There were no significant differences in sex distribution, visit status Cooperative Medical Scheme Office of Shandong, China. or age group distribution between patients in NCMS and non-NCMS villages (Table 1). The average age of patients was 37.3 years in Data collection in village health stations NCMS villages and 35.5 years in non-NCMS villages. Generally, about half the patients were females, and 70% were making a first Village doctors do not usually keep formal medical records of visit for the health condition treated.
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