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Older Miao People and Rural Health Policy in China

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Older Miao People and Rural Health Policy in China Older Miao People and Rural Health Policy in China Lin Yuan BA, MSc A thesis in fulfilment of the requirements for the degree of Doctor of Philosophy HEALTH EQUITY AND SOCIAL ORGANISATION TEAM AGEING AND HUMAN DEVELOPMENT RESEARCH GROUP FACULTY OF HEALTH SCIENCES THE UNIVERSITY OF SYDNEY March 2012 © Lin Yuan 2012 This work is copyright. Lin Yuan Health Systems and Global Populations Research Group Faculty of Health Sciences The University of Sydney PO Box 170 Lidcombe NSW 2141 Older Miao People and Rural Health Policy inChina CANDIDATE’S CERTIFICATE This is to certify that the thesis entitled Older Miao People and Rural Health Policy in Chinahas not been submitted for any other degree to any other university or institution of higher education. The source of the information herein is original and is solely the work of the author. _____________________ Lin Yuan ABSTRACT Aims: The new Rural Cooperative Medical Scheme (RCMS) was introduced in China to address the longstanding difficulties that rural Chinese experience in accessing appropriate health care. Little is known, however, about the responses to the Scheme by the residents of rural areas, particularly older people. This absence of knowledge and understanding is especially acute in relation to China’s sizeable ethnic minorities who tend to live in the poorest and more remote parts of rural China. Accordingly, this exploratory study investigated the experiences of the new RCMS by elderly Miao people in a rural township where there is a significant concentration of older Miao people. It focused on the barriers and opportunities that older Miao people face in accessing health care since the introduction of the new RCMS. Methods: The study adopted qualitative research methods including semi-structured interviews, focus group discussions and participant observation. Data were collected from the 31st of January to the 29th of April, 2008 and all data were collected from three groups of participants: Miao older people, public officials with a health policy implementation role and local public and private healthcare service providers. Findings: The results showed that older Miao participants experience poor living conditions, poor health, high mortality of their children and very limited access to adequate health care under the new RCMS. The number of qualified health professionals is limited, medical infrastructure and equipment, including medicines, are inadequate, and lower level health professionals experience poor working conditions. At the same time, unfavourable government treatment of private health services was manifest in the fact that patients could not be reimbursed through the new RCMS for private health services provided outside the village. At the village level most services were provided by health workers who were minimally trained and whose charges were very low. The villagers, including older Miao people, mainly relied on this provision for their healthcare needs. Similarities and differences in the views of public officials at different levels regarding the efficacy of the RCMS were examined. All of the officials thought that the new RCMS was a good scheme that would benefit the health of rural agricultural workers. Higher level officials believed that the agricultural workers should pay membership fees to belong to the new Scheme but township and village level officials thought that the collection of fees was a waste of time and energy. Conclusion: The most basic and obvious healthcare needs of ethnic Miao older people are a long way from being met by Chinese healthcare systems. Health inequalities exist between urban and rural Chinese, particularly among the rural Miao elderly. The health of older Miao people and their healthcare are closely associated with the medical services available to them. Older Miao people in this rural area have not obtained significant benefits from the new RCMS according to the views of the health professionals and managers. The limitations of the new RCMS in relation to older Miao people’s access to and experience of health care are also strongly influenced by the poorly provisioned administration of the Scheme as reported by the officials who participated in this study. Health system governance in China is intensely centralised in terms of decision-making and resourcing. There is little interaction between central policy-making processes of the government and local conditions and requirements. Further, there are no separate public sector mechanisms for implementing, supervising, monitoring and evaluating policy as there are in liberal democracies such as those that prevail in most OECD countries. Finally, while China is experiencing the development of organisations outside the state – NGOs – that indicate the emergence of civil society and avenues for community participation, these remain embryonic. Significance: The study has contributed to current knowledge and understanding of the kinds of social relations and practices involved in the implementation of the RCMS in rural China. It has potential to inform ongoing development of health policy and service processes in ways that will enhance the health outcomes of marginalised ethnic minorities, particularly older people, in such communities. Keywords: Older Miao People; Rural Health Policy; Rural Chinese, Administrative Structure; Rurality; Ethnicity; Ageing; the New RCMS; Ethnic Minority Older people; Chinese Government; Health Insurance; Healthcare Access TABLE OF CONTENTS VI TABLE OF CONTENTS ABSTRACT……………………………………………………………………………………………………………………………………………………IV ACKNOWLEDGEMENTS…………………………………………………………………………………………………………………………………X LIST OF ABBREVIATIONS…………………………………………………………………………………………………………………………….XIII LIST OF FIGURES AND TABLES……………………………………………………………………………………………………………..…….XIV INTRODUCTION ............................................................................................................................................... 1 RESEARCH QUESTIONS .............................................................................................................................................. 4 AIM AND SIGNIFICANCE OF THE STUDY ......................................................................................................................... 5 ORGANISATION OF THE THESIS ................................................................................................................................... 5 CHAPTER 1 SETTING THE SCENE: HEALTH EQUITY, HEALTH INSURANCE POLICY AND OLDER PEOPLE IN CHINA ........................................................................................................................................................................ 9 HEALTH EQUITY....................................................................................................................................................... 9 HEALTH INSURANCE POLICY ..................................................................................................................................... 10 Health insurance policy in China: The rural-urban divide ............................................................................ 12 HEALTH POPULATIONS AND EQUITY: AGEING, RURALITY AND ETHNICITY ............................................................................ 15 Ageing .......................................................................................................................................................... 15 Rurality ......................................................................................................................................................... 16 Ethnicity ....................................................................................................................................................... 17 CHAPTER 2 CHINA’S NEW RURAL COOPERATIVE MEDICAL SCHEME (RCMS): HEALTH EQUITY AND OLDER PEOPLE .......................................................................................................................................................... 20 HISTORY OF THE RCMS .......................................................................................................................................... 21 CHARACTERISTICS OF THE NEW RCMS ...................................................................................................................... 24 STRUCTURAL OVERVIEW ......................................................................................................................................... 26 The administrative system ........................................................................................................................... 29 National level ............................................................................................................................................................ 30 Provincial and area level ........................................................................................................................................... 30 County level ............................................................................................................................................................... 31 Township and village level......................................................................................................................................... 32 Achievements of the new RCMS................................................................................................................... 33 Identifying problems ...................................................................................................................................
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