Of 56,683 records screened, 279 full-text articles were assessed for eligibility, and 71 articles that fit the standards were included in this study (fig. 1).
Characteristics of RUMWs and features of their health needs
RUMWS have long been considered a vulnerable group due to their: poor education[14, 21, 26, 40], poor living conditions[14, 15], long working hours[14, 21, 40], and low income[14, 40]. They are lacking in social integration in the city[14, 15, 34, 54], and mainly rely on their kinship and friendship for social support[14, 34]. More than half of them move across provinces (27.2%) or across cities (32.9%) when they are young[55], but inevitably will return to their hometown when they are too aged or too ill to support their floating life[40]. They usually do not have special skills, and typically take temporarily work in private sectors, as state sectors usually reserve jobs for locals or skilled workers[14, 19, 40, 56, 57]. Most of them are discriminated and treated as a low-cost labor force. But sometimes they are also acclaimed as contributors to urbanization and economic development[14, 16, 17, 28, 33, 38, 58]. Therefore, most RUMWs have a high work mobility and low job stability, placing them in a disadvantaged and marginalized socioeconomic position[33].
The inherent characteristics of RUMWs have inevitably shaped their health needs featured by: (1) They exhibit better physical health [17, 19, 40, 59, 60], but worse mental health than local residents[17, 19, 34, 59]; (2) Except for industrial injury, they are less likely to suffer from serious diseases, but are more likely affected by common ailments, infectious diseases[15, 60-62] or sexually transmitted diseases[63]; (3) Their needs for healthcare and medical services are often delayed in their life time and the origins of their illness are often hundreds miles away from where they end up [14, 34], as they devote their young and healthy bodies to the flow-in cities, and bring their older and ailing bodies back to the flow-out place[40]. The question is: What makes RUMWs in China suffer from the current healthcare system? By reviewing existing literatures, we have identified two major barriers.
Barriers to effective health insurance coverage among RUMWs
Barrier 1: Difficulties for RUMWS to be included into the healthcare system in the flow-in areas
In the 1980s and 1990s—the early decades of China’s economic reform, welfare reform was subordinate to economic development[64]. The Chinese government developed a “conservative welfare system” based on labour contracts, and sought to lighten the burden of state-owned enterprises[38]. The measures included abandoning the commitment to provide permanent employment, creating unemployment insurance and a minimum living allowance scheme, as well as establishing an employment-based social insurance programme[38, 64]. Even so, the central government did not take fiscal responsibility or took very little[28], but decentralized its power to local governments, which lead to the welfare system mainly being financed at the local level[38, 65].
For local governments, even today, the local GDP growth rate is one of the most important political performance indicators[38]. Therefore, local governments are caught in a dilemma. On one hand, they need to expand welfare coverage to attract skilled migrants to contribute to local economic growth, but this raises the labour costs and increases local finance burdens[38]. On the other hand, they are reluctant to bear too much financial burden, while they need to control labour costs to attract investment funds[38]. To compromise effectively, the local government expanded the welfare coverage to the RUMWs with desired skills and qualifications[33, 38, 65].
The business sectors also face a similar dilemma as the local governments[66]. Since both the employee and the employer need to contribute to the employee’s welfare account, the high work mobility and low job stability of RUMWs could increase the burden for the employers[38]. What’s more, the Labour Contract Law bundles the health insurance premium with other welfare programs, such as pension insurance, unemployment insurance, on-the-job injury insurance, maternity insurance, and housing provident fund[38, 58, 66-68]. Therefore, providing health insurance cannot be separated from other social welfare provisions and the burden for local governments and business sectors are has inevitably increased[38, 66]. As a result, the business sectors – especially the private enterprises[65, 68] and small and medium-sized enterprises (SMEs)[69] – have adopted a similar strategy trying to avoid providing insurance coverage to all RUMWs[65, 66, 70, 71]. Some enterprises choose not to sign formal labor contracts with rural migrant workers[65, 72], evidences of which can be found in studies revealing that urban-to-urban migrants are about 1.5 times more likely to sign a labor contract than RUMWs[57], and also 1.5 times more likely to participate in at least one social insurance in contrast to RUMWs[57].
But the barriers for RUMWs to be included in local healthcare and welfare systems are also rooted in the fact that RUMWs often have less accessibility to relevant information [14, 15, 26, 38, 71]. Such situations have been greatly improved recently [38, 65]. However, even though the local governments have now developed greater financial capacities to accommodate people that they had excluded before, lacking assistance from government or nongovernment organizations[15, 28, 57] coupled with their disadvantaged and marginalized socioeconomic status, RUMWs are still in a weak position when negotiating with their employers[8, 65, 70]. Moreover, a majority of RUMWs in China obtained employment from their kinship or people from the same origins (laoxiang in Chinese)[38, 66]. Due to traditional customs, most of their employment was arranged based on trust but not on contract[38, 57]. Additionally, since many RUMWs leave to work in urban areas very young and are not willing to stay at the same place very long, some of them do not think it necessary to sign a contract and co-pay the healthcare premium [15, 70, 71, 73].
Even when RUMWs sign a formal contract with their employers, they are sometimes hired by subcontractors or labor dispatch companies, and thus their labour relationship with their true employers are not clear and cannot be fully protected by the Labour Contract Law[14, 15, 57, 68]. Similarly, in cases where the employers refuse to pay premium for RUMWs [26, 66], the accountability of the employers are not supervised or well-regulated.[15, 26, 68].
Barrier 2: Fissures among existing health insurance schemes leaves no room for RUMWs to meet their primary needs
Due to the fragmentation of its healthcare system[15, 38, 70, 71], health insurance portability or transfer in China is low[38, 65, 74-77]. More recently, there have been reforms in both healthcare sector and social security sector, which leads toward the integration of NCMS and URBMI[78, 79]. As a result, the fragmentation of China’s health system should be greatly reduced. Yet the fissures between NCMS and URBMI or UEBMI still exist. Specific barriers that hinder the portability of health insurance are summarised in Table 1, and elaborated below:
- Low portability between URBMI and NCMS for RUMWs. “Health insurance portability” means that an insurance holder can transfer his/her insurance from one plan to another plan, and from one place to another place[76, 80]. As the World Bank report of “The Path to Integrated Insurance Systems in China”[81] suggests, the integration of NCMS and URBMI will increase the portability of both NCMS and URBMI. However, both insurances are registered based on the unit of family, while most RUMWs migrate to cities without having their families with them[57, 66]. Participating in URBMI in the flow-in place will leave their families uninsured. Whereas the left-behind elderly family members are often the primary users of NCMS in the flow-out place[66]. Such a dilemma leaves the RUMWs no choice but to keep NCMS for their families while having themselves uninsured.
- Incompatibility between UEBMI and NCMS for RUMWs. Both UEBMI and NCMS have a risk-sharing account, and UEBMI also has a individual account funded by the employees such as the RUMWs. The risk-sharing account for UEBMI is funded by the employers, while the one for NCMS is funded by both the government and the family. The contributions from the employers and the local governments have a strong and direct influence on the affordability and sustainability of local social welfare system. Therefore, by no means the local governments are willing to transfer out the funds in the risk-sharing accounts of UEBMI or the funds paid by the government in NCMS[74, 80]. Currently, only the funds in the individual account of UEBMI and the funds contributed by the family in NCMS[74, 80] can be portable. Moreover, even if the RUMWs are allowed to transfer from NCMS to UEBMI, they are less likely to do so due to the economic burden induced by high premium for UEBMI[14, 38, 69, 70, 82].
- Including RUMWs into the migrant work health insurance (MWHI). MWHI is a plan specifically designed to solve the health needs resulted from the increasing number of migrant workers. Despite the variance of MWHI across places, almost all MWHIs are featured by low premium, mandatory employer contribution, and inpatient first[14, 83]. MWHI considers the low income of RUMWs, but it is still a voluntary program and only effective after signing a formal labour contract. Therefore, as outlined in Barrier 1, issues such as reluctancy of the employers to offer health insurance for RUMWs also applies to MWHI. Additionally, only offering risk protection for inpatient services is essentially a mismatch with the health needs of RUMWs[71, 84]. MWHI has almost zero portability, which is also incompatible with the RUMWs’ high place mobility and low job stability[71, 85].
- Keeping the RUMWs covered by the NCMS in their flow-out place. In fact, this is what most RUMWs choose to do in reality[19, 26, 86-88]. About 60% of RUMWs stay in the NCMS in their flow-out place, as shown in Table 1. However, the use of NCMS is largely bounded by geography. With the development of NCMS, it has become normal for NCMS to cover services beyond their municipal or provincial boundaries. However, most of the time, only hospital services are allowed to be reimbursed through NCMS across borders; no primary health services are included[89, 90]. As a result, RUMWs’ most fundamental health needs cannot be met by such mechanism.
Policy gaps in existing solutions to increase effective health insurance coverage of RUMWs
Two newest reforms are deeply related to the benefits of RUMW. One is the implementation of Interim Measures for the Transfer and Continuation of Basic Medical Security Relationships of Migrant Employees (launched in 2010 and modified in 2016)[36, 37]. Another one is the integration of WMHI into UEBMI. However, both solutions have problems that prevent the RUMWs being effectively covered by health insurance.
Policy gap 1: Lacking detailed policies has exacerbated fragmentation and is not helpful for health insurance portability
The Interim Measures is a national level solution to the geographical exclusion caused by mobile employment, which allows insurance transfers between regions or between plans. It is an important policy to achieve effective coverage of the Chinese UHC. In the 2010 version of the Interim Measures[36], the stipulations related to RUMWs are: 1) no double coverage by the three basic SHI (i.e., NCMS, URBMI, and UEBMI); 2) the government flow-in area cannot refuse the migrant worker from taking part in the local SHI using the excuse of hukou; 3) the RUMW, who has a stable labour relationship with a local institution, should be covered by local UEBMI; 4) the RUMW, who has an unstable labour relationship with a local institution, can voluntarily chose to keep their insurance in the flow-out place or to utilize the local basic health insurance; and 5) when the RUMWs return and if they still hold the rural hukou, they need to re-transfer their insurance back to the NCMS in their hometown.
However, none of these five stipulations consider the dilemmas faced by RUMWs illustrated above. The fifth stipulation can even cause loss in benefits to the RUMWs if they are covered by the UEBMI in their flow-in place. In addition, a lack of details in the Interim Measures has exacerbated the fragmentation among local policies since each place has developed their own operational approaches for the SHI relationship transfer[74]. Studies also show that the transfer of health insurance for migrant workers does not work well[77, 80], especially for those who have high mobility[71, 72, 91]. Finally, what is noteworthy is that the ideas behind second and fifth stipulation are against with each other. The former one tries to weaken the influence of hukou, while the later one actually strengthens it.
In 2016, the Interim Measures were modified[37]. The newer version deletes the above five stipulations and seems to increase the mutual portability among three SHI. But how to understand and implement the Interim Measures almost completely depend on the local government. Due to the lack implementation details, local governments who have already formed their own rules are less like to revise or make the implementation more effectively[38]. More critically, the same as the 2010 version, the 2016 version does not touch the risk-sharing accounts that are highly related to the benefits of the local government. Problems elaborated in Barrier 2 are not tackled and the RUMWs’ primary health needs are not dealt with.
Another problem for current policies is the ambiguous description of eligibility. For most policies, the eligibility of local health insurance for the RUMWs is based on stable labor relations. However, what the stable means is not clear[38, 83]. This also gives the employer a chance to evade their responsibility, if they recruit workers from subcontractors or labor dispatch companies[14, 15, 57]. An additional question is which insurance self-employed RUMWs are eligible for, WMHI, UEBMI, or URBM? The related description about them are usually absent[14, 71, 83]. For instance, in Table 2, we will introduce next, none of Beijing, Shanghai and Shenzhen gave a clear statement.
Policy gap 2: Forced integration of two very different insurance plans may worsen the exclusion of RUMWs
The MWHI is specially designed for migrant workers. However, it has exacerbated the fragmentation of Chinese insurance system. In the trend of integration, some places have begun to discard the migrant insurance, and integrate it into UEBMI or merge it with other health insurances. Table 2 compares before and after the reform of MWHI in Beijing[92-94], shanghai[95-99], and Shenzhen[100-102]. MWHI is similar with NCMS in the view of insurance type, hence the difference between MWHI and UEBMI is significant, and previous comparison between NCMS and UEBMI also suit to MWHI and UEBMI. Integrated MWHI into UEBMI means a higher costs to RUMWs themselves, government and enterprises, and the selectivity motivation of government and enterprises is higher in via of UEBMI than MWHI. Therefore, before solving of the conflicts of stakeholders’ interests as well as the problems faced by RUMWs, it can be speculated that the forced integration will worsen the exclusion of RUMWs from the urban insurance system, especially for those who are treated as unskilled workers.
Domestic and international innovative approaches to improve the effective health insurance coverage for RUMWs
Domestic innovation cases
Among MWHIs in China, the model used in Shanghai and Shenzhen are considered positive examples[8].
As shown in Table 2, Shanghai provided insurance coverage for RUMWs through its comprehensive insurance system before 2011. Though this model was replaced by UEBIMI in 2011, its biggest innovation is that it was a model based on commercial insurance. Researchers advocated that this model should be promoted as it can be well suited to RUMWs’ high mobility and low stability because commercial insurance is not restricted by region[8, 83]. However, based on our earlier review, unless the premium under this model is paid by RUMWs themselves or by the government in their flow-out place, the commercial model still does not provide a good solution to the extra-cost problem, caused by RUMWs’ high mobility and low stability and faced by the government and enterprises in the flow-in place.
The innovation of the Shenzhen model lies in it combining all health insurances into one after 2014, and in it meeting different people's needs by providing optional packages. The advantages of this model are that: 1) it reduces the fragmentation between plans; 2) it overcomes the barrier of using the family as the minimum financing unit, and then increasing the portability of health insurance; 3) the optional packages are more compatible with the low incomes of RUMWs; 4) it covers outpatient services and meets the RUMWs’ health needs; and 5) it is financed monthly and is more compatible with RUMWs’ high mobility. However, there are some weaknesses: 1) it lacks details of the eligibility of the self-employed RUMW; and 2) similar to the Shanghai model, the extra-cost problem still exists, caused by the RUMWs’ high mobility and low stability and faced by the government and enterprises.
International experiences
Table 3 summarised what can be retrieved approaches implementing in other countries or territory that face a similar problem as China.
USA[103, 104]. To meet the health needs of migratory and seasonal agricultural workers (MSAWs), the US offers funding to community health centres or clinic sites to directly enhance the accessibility, availability, and affordability of primary care and occupational health. MSAWs who do not have health insurance will be able to pay for services based on a sliding-fee scale, and payments are based on income and household size.
Kerala of India[105-107]. There is much in common in the strategy adopted in Kerala and China, such as establishing separate health insurances with low premiums, a need for work-related proof, voluntary coverage, and hospital services first. The difference is that the health insurance in Kerala is bundled with accidental death compensation, and hospital services offered in designated sites are free.
Thailand[108]. In 2001, the Thai Ministry of Public Health established migrant health insurance for all migrants. Its features are: 1) weak eligibility constraints, both documented or undocumented migrant workers are eligible; 2) voluntary participation, migrant workers need to pay a high premium (almost 455 RMB per year in 2015); 3) coverage of services similar to the scheme for local people, and also the inclusion of services that meet migrants’ needs, such as communicable diseases, health prevention, and health promotion; and 4) enhancement of service accessibility and acceptability by emphasizing migrant-friendly services.
Australia[109, 110]. For internal migrant workers, Medicare in Australia covers all of its citizens for free, while for external migrant workers, health insurance is bundled a Visa application.
Europe[111, 112]. Migrant workers are common in the EU. They migrate frequently between countries for their jobs, and the difference between countries is largely due to cultural and institutional differences. The biggest feature of the EU approach is that they receive the difference between countries, and steer clear of building one European system for all, but enhance the coordination among members from a legal level. The aim of regulations in the EU is to determine which national legislation applies to a migrant worker in all possible cases, and to avoid a situation where migrant workers are either insured in more than one Member State or not at all. The regulations have the following characteristics: 1) detailed explanations. For instance, in article one of the regulations, it exhaustively enumerates and describes the definition of 27 related terms; 2) avoiding ambiguity. For instance, because of the situation, people may have business locally but not be employed locally. The definitions the regulation offer are “activity as an employed person” and “activity as a self-employed person” rather than definitions of a “worker” or “self-employed person”; 3) only providing the principles and leaving space for the member states, but the contents involved are comprehensive. For instance, contents include how to treat migrant workers, what rights and interests should be guaranteed, how to handle people who are double covered by multiple countries or people not covered by any country, how to solve the problem of reimbursement for medical treatment in different places, how to deal with the cumulative of the set period, and how to cooperate and exchange between institutions or countries. Therefore, the European Commission not only provides guidance but more importantly offers coordination. Finally, for migrant workers, the European Health Insurance Card is used to conveniently access health care during a temporary stay abroad.
In summary, the migrant-workers’ problems of insurance coverage or accessing to health services, countries who have a national health insurance are more likely to demonstrate the advantage of their system. Establishing a separate health insurance with low premiums for migrant workers is not a unique approach in China, but other countries consider more the migrant workers’ characteristics, including low incomes and the need for more primary care. Based on the causes of the problems and the obstacles encountered in solving these problems, the European approach is the most instructive for China.