—A Qualitative Study in Meedu County, Yunnan Province, China

1. Why Some Rural Farmers in Chinaare Reluctant to Accept Governmental Offersin NCMS(the New Cooperative Medical Scheme) —A Qualitative Study in Meedu County, Yunnan Province, China Presented by: Yiyun Zhang (HSSIP, Mahidol University)

2. Outline: • Background • Research objective • Methodology • Major findings

3. Background 1. From CMS to NCMS: Efforts of the Chinese Government for Rural Health • CMS (the Cooperative Medical Scheme) • Health protection net • Vicious circle • NCMS (the New Cooperative Medical Scheme) • Four basic principles of NCMS are • 1) Voluntary Participation, • 2) Risks sharing, • 3) Focusing on catastrophic diseases • 4) Being managed by government.

4. Background (Cont.) 2. New CMS: What is the “New”? • government provides subsidy • government provides management availability—accessibility—affordability

5. Background (Cont.) 3. NCMS Expansion: the Expected Coverage and the Grass-Root Advocacy • more enrolled members, less shared risks • national plan, local plan • yearly run, yearly recruited • various advocacy activities designed

6. Background (Cont.) • experienced difficulties • identified reluctance

8. Background (Cont.) 4. Rural Farmers’ Reluctance: What Makes the Barriers of NCMS Further development? 5. Meedu County: Undergoing NCMS Development as An Earliest Pilot • National impoverished county • Five years piloting: 2003, 68.95%—2007, 92.42% • Clear reflection of NCMS development

9. Research Objective • To explore reasons behind rural farmers’ reluctance to accept governmental offers in the national NCMS • “active” • “reluctant” • didn’t enroll • enrolled with hesitance • would have not enrolled if they could fully express their opinions

10. Research Methodology 1. Research Design • Observation • Participant observation • Non-participant observation • Informal inquiry • In-depth interview

11. Research Methodology (Cont.) 2. Sampling • Sampling unit: “family” VS “villager” • Haibazhuang Village • 12 rural families • Responded person in the family

12. Research Methodology (Cont.)

13. Research Methodology (Cont.)

14. Research Methodology (Cont.) 3. Data collection and data analysis • Existing documents • Photos • Voices • Notes records, notes management • Mapping and interpreted coding • Using coded numbers: confidentiality

15. Major Findings 1. The designed NCMS regulations and the reluctance at two extremes: the poorest and the richest —support and attractiveness

16. Major Findings (Cont.) 1.1 Ten Yuan premium: the barrier for the poorest to enter • Meedu County 843 Yuan • Haibazhuang Village 2842 Yuan “This year, the autumn harvest for rural farmers is not very optimistic. First, for those who grow tobacco, they got the loss due to the infected disease of tobacco; second, for those who feed pigs got the loss of the pig murrain; third, for those who grow garlic, they got the loss because of the dropped price of garlic this year…”

17. Major Findings (Cont.) • Behind the average line… “when the advocating persons came to my oldest son’s house to collect the premiums to enroll NCMS, we cannot raise it (50 Yuan totally). After several visits we still cannot raise the money, then they stopped. The biggest problem for us is the money. We have no circulating money. It is like grinding, to expect something to come out, you have to put something inside to grind first. We have nothing to put inside, how could we expect to take something out?”

18. Major Findings (Cont.) 1.2 A high co-payment and a low ceiling: not supportive enough for the poor and not attractive enough for the rich “(I didn’t enroll is because) I just feel I am not interested in NCMS. Do you think that I lack of money to pay the 10 Yuan premium? No, 10 Yuan is just a pack of cigarette for me. My wood factory has a good annual profit, I can make enough money for my family a good living, if we get sick, we just go to the best hospital and pay by ourselves. No need to expect the small amount of money returned back by NCMS. I can earn the maximum reimbursement within one month.”

19. Major Findings (Cont.) 2. Not only “adverse selection”: the healthy and the most sick • The healthiest: we never get sick! • The healthy: we have no big problems • The newly-recovered: am I so bad lucky in getting sick? “I have been so sick last year already, how can I get sick so soon again within this year? Unless the god loves me too much and gives me so much bad luck!” (laugh) • The sickest: we gave up already

20. Major Findings (Cont.) 3. Rural consumption priorities: production, children, education, and then? Completely impossible to put 10 Yuan aside for the NCMS yearly enrollment? 3.1 “Pan Tian” (farming): the biggest event scheduled by our rural land “I don’t know whether I will be healthy or not in next year if I don’t enroll NCMS; but I do know that I will have no harvest in next year if I don’t grow them!”

21. Major Findings (Cont.) 3.2 Children: they should be the one that free from experiencing our poverty “All the other kids will have new things, how could our kid has nothing new in the new semester?” 3.3 Education: no education, no future! “Just go back and continue your class. Daddy will raise the money for you!” 3.4 Others: unavoidable expenditures • attended the wedding party • ceremony of worshiping our passed away senior family members.”

22. Major Findings (Cont.) 4. Migration phenomena: the outside job and the hometown health care • attractiveness from the urban cities • rural “Hu Kou” and rural social welfare “By the statistics from the National Statistic Center, there are 1.2 billion rural farmers migrating to urban cities to find a job.” “Now, it is very popular to go out (to work), staying at home and farming can only lead the simplest life. If it is not because of my old age, I also want to go out. But old people like me (55 years old), are difficult to be hired.”

23. Major Findings (Cont.) 4.1 Migration plans and the NCMS enrolling possibilities —different aims, different choices • work nearby • work out for a few years • never come back 4.2 Migrant labor workers: can the small private clinics outside our hometown be covered by NCMS? • far away from home • small private clinics • governmental hospital • regulation: available, but not beneficial

24. Major Findings (Cont.) 5. Religious believes: Health from the Buddha’s mercy or the government offers • local religious believes and health issues • praying for health & expectation • government offers in NCMS

25. Major Findings (Cont.) “Do you believe that this is a true story happened in our Meedu County last year? During the period of NCMS advocating and premiums collecting, there was a rich family in Village X, the male host refused to enroll NCMS no matter how hard the NCMS advocating personnel tried to persuade. But, several days later, that village decided to build a small temple and announced to recruit voluntary donations from village members. When the donation name-list was posted out, that rich family who were reluctant to enroll NCMS ranked on the top—they donated 500 Yuan!”

26. Major Findings (Cont.) 5.1 The re-prospered practices as the localized rural culture • temple activities naturally become part of their life. Even a certain amount of time and money is spent as routine necessities. “I like to join the one that wish the whole family to be safe from any disturbances most.” “Every time after I made my wishes, I would put some money into the blessing box. It is not suitable if you made a wish but didn’t put any money. It is not the money to be counted, but your sincerity to be showed”

27. Major Findings (Cont.) 5.2 Government offers: tailored from rural farmers’ wishes? • Contrasting: voluntary VS reluctant “I am very sincere in believing Buddha, and Buddha responds me well. I prayed Buddha to give our family a good farming year, then this year our harvest of corn is not bad while other villagers got loss from the dropped price of garlic; I also prayed my grandson could go to high school in the county town, then he passed the exam and got the acceptance; and I prayed Buddha to keep our family in his protection, then this year all our family members are healthy… I feel very happy if my prayers for the family turn to be true, and I appreciate the Buddha more.”

28. Major Findings (Cont.) Whisper to the Buddha: different difficulties, different wishes Buddha’s response: “fits my wishes” Government offers: a general response to fit all the posted difficulties and varied wishes? however, more efforts that are putting on

29. Major Findings (Cont.) A less-developed rural county, while rural farmers, who have just crossed a series of complex decades, are experiencing changes of the new era. Comparing to the old ways of praying in front of Buddha, rural farmers are not impressed enough to get familiar with the government’s new style of providing support and care.

30. Major Findings (Cont.) Get ready for accepting NCMS as governmental offers more understanding from rural farmers more improvements from the government It is expected that following the trend of government’s active trying, in the near future, problems related to rural health, those whispers to Buddha from rural farmers could be responded by the government as well.

31. Thank You !