China's Rural Cooperative Medical Care System Evolution Mechanism

Rural cooperative medical care system is the centerpiece of rural medical security system. Its improvement, development and evolution play an important role in relieving the farmers' heavy economic burden from the medical care, improving the balanced development of both rural and urban areas and constructing a harmonious society. In history, our rural cooperative medical care system evolved unsteadily. In reality, the new type of rural cooperative medical care system has a series of problems in its operation, such as the incompleteness of the supervising system, the rapid rising of the medical care expenses and the rather low security level. All of these also deepen the instability of the system. In theory, it lacks researches on the evolution mechanism and the dynamic balanced mechanism of the rural cooperative medical care system from the perspective of system evolution. Therefore, it has positive theoretical and realistic significance in managing the internal defects of the present system, promoting its sustainable development and optimizing the evolving pattern of the rural cooperative medical care system if we study the evolution mechanism and the game-playing relations of the rural cooperative medical care system from new perspectives, mixing the system evolution analysis theory, public products theory and game-playing methods together.Aiming at the changes of our rural cooperative medical care system, this dissertation, from the perspective of system evolution, builds up the theoretical framework of the systematic evolution analysis, constructs a dynamic balanced evolution model of the changes of our rural cooperative medical care system and multi-elements decided model of its evolution and analyzes its evolving mechanism combining the different elements which have influenced those shifts in different historical periods. By applying the game-playing research instrument, this paper analyzes the static and dynamic gaming-playing structures between the disposing subjects which play a decisive role in the evolution of the rural cooperative medical care system. Thus, it extracts the conditions that have influenced the medical care system and those that have influenced the stability of the balance. It sums up and explains the evolution types, patterns and their defects of the rural cooperative medical care system combining the analyses of the role the government plays in different period. Meantime, it suggests the ways to realize creativity in the system. It predicts and judges the direction of the evolution in a long run and points out the evolving roads and objective patterns to construct a rural-urban basic medical insurance system via the analyses on the defects of the system in which the rural and urban areas are separated and exposing the necessity of constructing a rural-urban basic medical insurance system.This thesis contains eight chapters. Chapter One is introduction. It depicts the research backgrounds, research significance and defines some relevant concepts. Besides it elaborates my train of thought on this research and the framework of the content.Chapter Two organizes and summarizes the related researches on rural cooperative medical care system and the relevant theories about system changes and system evolution. It tries to pave ways for the following chapters concerning creative researches on the evolving mechanism of the system on the basis of present theories and the previous researches. Furthermore, it points out that the studies on the evolution mechanism and game-playing relations in the academic circles still have some defects and blanks.Chapter Three recalls the process of the changing Chinese rural cooperative medical care system. It concludes the system management, the operation mechanism and the characteristics of the system in different periods, providing the following chapters with the history and backgrounds of the system evolution. Moreover, it analyzes the evaluation on the results of the present new type of rural cooperative medical care system from the perspectives of efficiency and equality. It finds that this system is inefficient in relieving the medical care burdens of the farmers and that, to some extent, it exists inequality in the result.Chapter Four points out a balanced evolution model of the changes of our rural cooperative medical care system and a multi-elements decided model of its evolution on the basis of the North's analyzing pattern of changing system theory and system evolution analysis theory. With the help of the balanced evolution model, it finds that Chinese rural cooperative medical care system is imbalanced, which is manifested in the coupling of the inner system and the outer system of the rural cooperative medical care system and the demand and the supply of the system. It becomes the intrinsic driving force of the system evolution. The imbalance is caused by a series of variables. That is to say, we may find the reasons from the system itself such as the coupling relation in it and its expense structure and they may be some external causes, political reasons, social structure, and the transformation of the economic structure, ideology, media promotion and so forth. However, among all these elements, the systematic environment the medical care system is in and the subjects who promote the system evolution are vital. They decide the evolution pattern of the medical care system and help it to form a "breaking-point" balance. Then they may become the "disturbing elements" to break the balance, resulting in the medical system facing a crisis again and a new circle of evolution taking place and then coming to the next systematic balance. All of these phenomena move in a circle, constructing the dynamic evolution of the medical care system. In the multi-elements decided model, it tells four types of elements influencing the evolution of the medical care. The first one is the systematic environment. The second one is the operating group. The third one is the efficiency of the system and its character and other internal variables. The fourth one is the public policy and ideology and other external variables. Among them, the subjects (the operating group) are the key variables. The constitution of the members, the comparison of the forces and the game-playing ability and so on may decide the arrangements of the medical care system to a large degree. This chapter analyzes profoundly how the systematic environment, the internal and external variables affect the evolution of the medical care system.In Chapter Five, because of the evolution patterns of the rural cooperative medical care system being decided by the game-playing equilibrium between the operating subjects, it begins to use game-playing theory to analyze the game-playing relations of the government, medical care institutions and farmers these three types of operating subjects in the new type of medical care system. It shows the balanced preconditions and the balanced situation of the system via the analyses on the game-playing equilibrium among the subjects. In the game-playing between the government and the medical care institutions, the latter one will treat the farmers more honestly if the inspecting cost of the governmental supervising sections is rather lower and if the medical care institutions will be punished more severely if they break the rules and if they may receive higher social effects thanks to their honesty. For the government, the less extra interests the institutions get from their dishonest treatments and the severer the punishment the government will take, then the smaller the possibility for the government to inspect their health care service is. The equilibrium situation of the game-playing between the government and the farmers lies in the net interests of both sides. The result of the equilibrium is that the government, under the control of maximizing the expected interests, will choose to organize and to instruct and to support the system and the farmers will participate in it according to their own will. Under this arrangement of the system, farmers may have the tendency to choose reversely because of information asymmetry and the serious-diseases-trend policy objectives. The game-playing equilibrium between the institutions and the government is decided by the following elements such as the extra profits gained by their dishonest treatments, the possibility of the farmers having some serious diseases, the compensations the farmers can get from the medical care managing sections of the system and the expenses the farmers need to pay. In this static equilibrium, it implies the moral risks conspired by the medical care institutions and the patients because the institutions intend to maximize its profits and their supplies induce demands in the information asymmetry situation. It exposes that it exists a series of problems in the system, such as the subject who needs medical care making reverse choices, the subject who supplies medical care inducing demands and the the two sides conspiring moral risks, because each operating subjects intend to maximize their expected profits. Therefore, it is easy to cause the instability of the system equilibrium. It points out that the stability of the balance lies in the supervising degree, supervising patterns of the government and the collective media spreading mechanism and other elements. Chapter Six analyzes the evolution types of the rural cooperative medical care systems in different periods in accordance with the role the government plays in the system. It exposes that the traditional rural cooperative medical care systems are the systematic evolution promoted by the joint efforts of the government who advocates it and the ordinary people who start to evolve it themselves and that the foundation of the new type is a government-promoted forced systematic evolution with the Pareto characteristics. It also analyzes the weak points of this kind of forced systematic evolution, such as it rejecting the independent creativity from the people, it being inefficient when coupling with other systems, it failing to meet the demands of the people for systems and it being difficult to take both the system and the operating subjects' interests into account and so forth. It further explains how the government plays a role and what roles it must play, analyzing and evaluating the governmental responsibilities and the impacts and problems which existing in the present new type of system. Furthermore, it explores the ways to let the system be creative. First, we need to optimize the evolution patterns of the rural cooperative medical care system, making full use of the creative forces of the people and the efficiency of the resources allocation in the market. So the intervening scope, limits and goals of the government in the system should be inspected and collated one more time. Second, the governing mechanism of the government in the insurance field should be perfected, for example, to adopt market competing mechanism, to found a third-side-paying balancing mechanism, and to build up a multisided, high-efficient funding mechanism, a scientific and reasonable expense-implementing mechanism and an open, just, efficient supervising mechanism.Chapter Seven aims at the rational prospects of the evolving direction of the system in a long run. It shows that the developing direction of the new type of rural cooperative medical care system is to clear up the separation between the rural areas and the urban areas and to merge in the basic medical care insurance system characterizing as uniting with the city medical care insurance system, all-residents included and operating rural and urban areas as a whole. Besides, it gives initial idea on how to construct a rural-urban basic medical insurance system. First, we need to improve the insurance level of the rural cooperative medical care system and to ensure access to the present medical care system for more citizens whole-heartedly. Then, we need to reconstruct the urban basic medical care insurance and the new type of rural cooperative medical care system. Last, we may found an overall rural-urban basic medical care insurance system.Chapter Eight is the conclusion of this dissertation. It tries to elaborate the main conclusions clearly, precisely, completely and accurately. In addition, it points out the creative work of this paper and the questions that need further research in the future.