The NRCMS is a crucial step in narrowing the insurance gap and improving equity in access to healthcare for rural populations in China. Through years of development, the security level and coverage of the scheme have been greatly increased and enlarged[11]. However, according to the data, per capita disposable income in the western region remained the lowest of the four regions in China by 2015. The appearance of this phenomenon is not only related to the geography and traffic environment of the western region itself, but also closely related to the development strategy carried out by Chinese government[12]. In terms of geographical environment and traffic conditions, the western region is deeply inland, with terrain of mainly plateau, and mountain-based, and its water source is limited, meaning that it is not conducive to the needs of human survival, production and large-scale economic and industrial construction. At the same time, single railway and highway conditions make it difficult to form trade advantages to promote regional economic development [13]. In terms of national policies, after the 1980s, the state implemented the strategy of speeding up the development of coastal areas, and the economic development of the eastern coastal areas accelerated. By the 1990s, the income of urban residents in the eastern part of the country had greatly increased, and the income of urban residents in the eastern region had greatly increased [14]. The income gap between the western region and eastern region has widened. Although since the reform and opening up to the outside world, the economic system was adjusted and the market economy system was established. However, because of its position, cross-border investment and overseas trade could not benefit the region, which further widened the economic level gap between the western region and the eastern region[15].
In addition, the study shows that the proportion of per capita medical expenditure in the western rural areas between 2000 and 2015 is also increasing year by year. As a result of the higher education level, quality training, medical facilities and services of the urban residents, compared with the rural areas, the structural differences between the urban and rural dualism are finally formed [16,17]. In addition, under the influence of many factors such as resource environment and historical culture, the further development of the western region has been restricted, resulting in a significant difference in the level of social security between rural and urban areas [18]. So, if there is a lack of financial input in rural areas’ social security in the system, especially for the farmers who lack of public medical security, the increasing costs of diagnosis and treatment will lose touch with reality of the farmers’ actual ability, and even makes them unable to pay alone. Therefore, developing countries should pay attention to improving the skills of rural residents in order to increase their productivity, income and profits. At the same time, the financing policies should be adjusted to narrow the gap between urban and rural residents.
This study shows that by the end of 2015, the average common bed space in rural areas of eight provinces is lower than the national standard. From the macro level, this phenomenon is mainly due to the serious shortage of local financial input, resulting in a large amount of infrastructure debt [19]. In the medical institution system of the central and western backward areas, because of the weakening of the original rural collective economic base, the capital input is not guaranteed, the management system is loose, and the facilities of the village health rooms are changed from the public to the private individual medical treatment points [20]. Medical equipment, diagnosis and treatment procedures, and other hardware and software facilities can not meet the national standards is a long-standing reality. Therefore, various public health funds and business development funds should be included in the budget, and with the increase of fiscal revenue, the proportion of investment should be gradually increased [21]. Through the financial investment of the government, the township health centers can be provided with medical equipment suitable to the rural reality, and the treatment ability and the level of treatment can be continuously improved. In addition, we should pay attention to the management and management of the existing rural medical and health resources, and effectively providing low-cost, high-quality medical and health care services to the vast number of farmers [22].
The level of education and specialty of medical staff in poor rural areas is generally low. This may be due to the low level of rural economy, low potential for development, highly educated medical workers believe that these areas are not developed, and pay is not high. In addition, the current national treatment policy in these areas is not attractive to senior health technicians, which is one of the important reasons for the lack of medical resources in the western region [23]. There is no alternation between the old and the new, and the structure of the medical staff is aging [24]. At the same time, there is a lack of necessary follow-up continuing education and training to current personnel, which means health care personnel do not understand the new medical and health technologies, and new means. [25] In this regard, how to realize the primary purpose is to create a high-quality, skilled grass-roots physicians? First, the establishment of village doctors professional qualifications admission mechanism, rural doctors must have professional qualifications or professional (assistant) physician qualifications; The second is to strengthen the rural primary health care personnel training, establish a life-long education system[26]. We can make full use of the three-level medical service network, and the rural health technicians at the grass-roots level regularly rotate to urban medical institutions for free training and further education, and at the same time, urban health technicians take turns in stages. Batch to the designated township health centers for technical support and assistance, and then achieve talent interaction[27]. Finally, improve the technical service ability and level of rural health personnel, promote the rapid development of rural health.
According to the survey of eight provinces from the perspective of government health expenditure. The results of this study show that the annual government health expenditure increases linearly in 2011–2016, and the difference between provinces is obvious. Because this model shows that the level of government health expenditure is related to the initial health expenditure and growth rate, and the initial health expenditure is significantly correlated with the growth rate (t = 17.606, p < 0.001), The difference of initial health expenditure is one of the reasons for the difference of government health expenditure among provinces. This is related to the financial pressure between different regions, where the level of fiscal revenue exists. Fundamentally, the difference is caused by the different levels of economic development in various regions, and is a manifestation of the irrational economic structure [28].The financing level of NRCMS is slightly different because of the difference of economic conditions among different regions. At first, the provinces with lower economic ability have lower investment in health resources, which also aggravates the pressure of residents in poor areas to get good social security. [29]. Therefore, the state should strengthen the adjustment of the balanced development of the regional economy, promote the balanced development of the regional economy, and solve all kinds of problems brought about by the unreasonable structure of the regional economy.
In addition, the study shows that per capita disposable income in 2013–2015 has a significant predictive effect on government health expenditure in the same period. This phenomenon may be due to the increase or decline in per capita disposable income, which determines whether residents have more capital to pay attention to medical conditions and the protection of their own health and. In turn, to propose the need for basic medical facilities and services, this requires the government to consciously adjust its investment in health care over the same period [30]. At the same time, the increase or decline of farmers’ disposable income means whether the government also has the corresponding disposable funds and the ability to strengthen the construction of medical care during the same period. Long term, the administrative function of the government is too prominent, and the absence of the public service function leads to the weakening of the rural medical and health service system. Therefore, for the underdeveloped areas, from the management-oriented government to the service-oriented government, the promotion of public functions such as education, health care and other public functions is a large number of farmers in urgent need of public services [31]. Only in this way can the rural medical service and insurance system be improved for a long time. If we do not break the “bottleneck” of the system and mechanism, it will have a great impact on the reform of rural social medical security.
Farmers as the main object of the NRCMS, their satisfaction with this system is one of the important indicators of evaluation. In this study, farmers’ overall satisfaction with the new rural cooperative medical care is not very high. In poor areas, due to the lack of public health services, the new system should have given greater benefit to the poor. Qi[32]suggests that the NRCMS decreased the poverty rate significantly and raised wealth for middle and low income families. Guo[33] found there existed inequality in reimbursement, saying that the reimbursement rate and ceiling benefited high income groups from getting more reimbursement. The technical level in rural hospitals is limited. For outpatients, usually the reimbursement rate is low. As for inpatients, they can only get the reimbursement certification from hospital after they discharge from hospital, especially for the long-stay patients. And many examinations and approvals are needed from every level of health care institutions. It may take at least one month to get compensation expenses after handing in the application. In addition, the technical level of rural hospitals is limited, and if participants need more medical services and move to higher-level hospitals, usually large hospitals in the city, the way to get compensation is too difficult. They can be compensated within a week or two after a designed hospital is treated. At the same time, in order to make full use of the limited funds, the amount of payment, the limit and the ratio of compensation are set when the hospital expenses are compensated[34]. In the case of high compensation rate and low upper limit, the compensation obtained by farmers is far from enough with structure. At present, government subsidies and complex reimbursement process are weakening the application and attractiveness of the system.
Various analyses have shown that the farmers’ will of participation is influenced more by subjective factors. Due to the fail of traditional cooperative medical care, the farmers have different worries about the future sustain of NRCMS. Worried about the stability of the system, they thought the expected return was low so they waited and saw it uncooperatively. Mao’s study showed that 67% of the non-participating farmers chose not to participate because they did not understand the new system [35]. When they find themselves enforced and unable to express their true opinions, they choose to participate passively. The emergence of this phenomenon, on the one hand, shows that advocacy is insufficient, on the other hand, the capacity of regulators appears to be weak, and there is a lack of effective financial restraint mechanisms and regulatory measures [36]. In order to increase participation, many local governments have chosen not to provide sufficient funding, compensation and other details, some even exaggerating the effect which masked the defects of the system, resulting in farmers lack of detailed information [37]. In addition, as an important beneficiary group, and lack of resilience to economic risks, farmers have a strong willingness to obtain financial protection. In the supervision mechanism established by the government, farmers’ participation space is relatively small, which limits the scope of farmers’ participation.
According to the game theory, each stakeholder will try to maximize its gain or to rationally receive a better future result in the process of regulation deciding. The stakeholders will interact with each other to a balance point and then new regulations will be formed. As a systematic project, the stakeholders in the NRCMS consists of the farmers, medical institutions, agencies and the government. Farmers are the foundation of the system, medical institutions are providers of medical services and medical insurance, and the government is the regulator. The success of the scheme depends on the coordination of the relationship among them. If the wealth not benefits the farmers but other members, properly the scheme isn’t being used optimally. Therefore, medical institutions, insurance agencies, governments and farmers should not be opposed to each other. A balanced and coordinated mechanism of interest linkage should be formed.