Yang Xiu-li，Sun Hang，Yang Qing-tian，Li Si-tong，and Yang Fei

College of Resources and Environment，Northeast Agricultural University，Harbin 150030，China

Revelation of Rural System of Medical Services in BRICS to China

Yang Xiu-li，Sun Hang，Yang Qing-tian，Li Si-tong，and Yang Fei

College of Resources and Environment，Northeast Agricultural University，Harbin 150030，China

In recent years，the great achievements of basic medical and healthcare services of BRICS have gained great attention and acknowledgement from the whole world. In their medical system reform，India，Brazil，Russia and South Africa have established their medical systems with their own characteristics. This provides valuable references for China in its critical stage of medical system reform. This paper explored the experience of BRICS' reform of medical system in order to offer some references and guidance for the establishment of basic medical and health services with Chinese characteristics and conforming to Chinese practice.

BRICS，rural medical and healthcare system，experience

Introduction

Since the formation of BRICS in 2001，its member states — China，Russia，India and Brazil — have been the common concern of the international community. With the joining of South Africa in 2010，its lineup becomes more powerful. In the past few decades，they have been attaching great importance to the development of their people's well being，and making great efforts to promote the reform and development of the medical and healthcare services in their own countries. At the 65th World Health Assembly in 2012，Chinese Minister of Health，Chen Zhu，Brazilian vice Minister of Health，Jarvis Barbosa and Indian Minister of Health and Family Welfare，PK Pradhan introduced the basic facts about the development of their own basic medical and healthcare services. Their medical system and related experience were approved by other countries in the world. India，Brazil，Russia and South Africa have established the basic medical and healthcare services with their own characteristics in accordance with their own conditions. But，they have a common advantage in their free medical services，marketized medical services and attention to the rural system of the medical and healthcare services. The new type of rural cooperative medical care in China has entered an important stage of reform after being carried out for 10 years. It has drawn some advanced medical service experiences from BRICS with similar economic conditions and social backgrounds. These advanced experiences will provide reference and guidance in further to promote the rural medical and healthcare services reform in China.

Characteristics of Basic Medical and Healthcare Development in BRICS

Basic medical security under free medical system

With the establishment of the medical security system，each BRICS member pays attention to the equity and accessibility of their medical and healthcare services. They've established their nationwide free medical system and ensured that each citizen has equitable access to basic public health services in its legalform （Fu and Lan，2011）. The implementation of the nationwide free medical system means there's no gap between urban and rural areas in their medical security and the accomplishment of urban and rural integration. Since its independence in 1947，India has established its almost free public medical and healthcare system. As the first constitution in 1949 stipulates，each citizen has a free access to medical services. The system mainly comprises the public medical services and the threelevel rural medical net. The public medical services includes five levels from national to rural hospitals. And they provide some basic medical services and public healthcare programs，to which every citizen has free access，such as nationwide birth control，preventive inoculation，nutrition improvement and rural water supply. The three-level rural medical net consists of Sub Center，Primary Health Center and Community Heath Center. It mainly provides medical and healthcare services for people in povertystricken areas. And some of the free programs cover registration，examination，hospitalization，treatment，emergency treatment and even the patients' food. But，the medicine expenses are not included for the time being. However，this will be improved，if the medical reform concerning free medicine for everyone is put into practice （Zhang，2008）.

Russia basically inherits the free medical system of the Soviet Union in establishing its medical and healthcare system. A few medical reforms have already been carried out in Russia. With the passing of Medical Insurance Act for Russian Federation Citizens in 1991 and Regulations Concerning Federal and Local Compulsory Medical Insurance Fund in 1993 （http://news.china.com/international/1000/20131202/1 8189263.html），Russia finally established the medical insurance system with the integration of compulsory insurance and budget appropriation being the first，and private healthcare being the second.

As early as the year of 1988，the Brazilian Constitution stipulated that each citizen was entitled to health and the state should provide wide-spread and equitable medical and healthcare services for each citizen. In 1990，the Unified Health System was formally established，under which the public hospitals and clinics provided free medical services to each citizen in accordance with the region-by-region and level-by-level principle. The Unified Health System in Brazil benefits the majority of its people，which made them have free access to primary healthcare.

Marketized operation of medical institutions

With the rising of the new public management movement in the 1980s，the efficiency of medical and healthcare services had been a major concern for each country in the world and marketized and commercialized operation model had gradually come into the sight of the medical reform of various countries. India，Brazil，Russia and South Africa introduced the market competition mechanism into their medical reform in the early period. While focusing on the development of the public hospitals，they have also lowered the standard of admittance for private medical institutions into the medical services，established the operation model of public and private partnership and realized the balance of efficiency and equity of their medical services.

In providing its medical services，India has always been giving more and more supports to and making more investment in its public hospitals. And at the same time，it also encourages the development of its private hospitals. The public hospitals in India pay more attention to the public healthcare with 60% of prenatal services and 90% of the preventive inoculation services. With regard to encouraging the development of the private medical institutions，India entitled its medical field to open to private and foreign insurance companies as early as the year of 1999. Such marketized medical services system largely promotes the development of Indian private medical institutions，making its proportion rise from 8% when it won its independence，to 67% in 1993 and to 93% in 2000，when it provided 75% of the nationwide medical service （Liu and Zhang，2009）. While strengthening the supervision of its private medical institutions，Brazil also actively encourages the development of its private medical insurance institutions. The private medical institutions in Brazil make up 75% of the total and the private health insurance covers 25%-30% of the Brazilian citizens. While promoting its medical reform，Russia vigorously supports the establishment of the private hospitals and at the same time makes an effective attempt in the privatization and marketization of public medical institutions. It has finally established a multi-service system with coexistence of both public and private hospitals. The medical security model combining all the compulsory medical insurance with private insurance largely relieves the Russian government of the trouble of the limitation and low efficiency in providing its medical services. In establishing its medical and health system，South Africa puts an emphasis on the target of equity，consistence，quality and efficiency. And the South African government creatively adopts the public and private institutions interaction model. With equal medical insurance right being ensured for every citizen in South Africa，and a strong and feasible medical service system is also established.

Efficient medical management system

Marketized development of the medical and healthcare services not only brings about improved efficiency of medical services，but also promotes high effectiveness of the medical management operation. After implementing quite a few medical reforms，the BRICS countries are all establishing their unified medical management system and paying great attention to the role of non-governmental organization in the medical management.

India has established a relatively comprehensive medical management system in its healthcare management and adopts vertical management. Two relatively independent agencies are established under the Department of National Health and Family Welfare: Health and Family Welfare Administration Bureau and Traditional Medicine Management Bureau. They are respectively in charge of disease prevention，medical services，medical research and traditional medicine management. Such segmented management makes clear the duty of each agency and improves the operation efficiency of the medical management institutions. After the medical system reform in the 1990s，Russia had established the management system consisting of healthcare management institutions，compulsory medical insurance fund and medical insurance companies. Under such system，the compulsory medical insurance fund is a semigovernmental agency responsible for medical appropriation and accumulation，allocation and use of insurance fund in a commercial management model （Dai，2011）. The medical insurance companies are independent operators，free from the management of the healthcare and medical institutions. Instead they can supervise the medical institutions. Brazil has established the Health Ministry administration system with the integration of medical treatment，insurance and medicine. It realizes their interactive development in the reform. As for the supervision of medical services，the medical administration，the medical councils of various levels and private insurance institutions are responsible. The Medical Doctor Association takes charge of supervision of doctors.

Attention to motivate development of rural medical and healthcare system

The basic rural and healthcare system supply lies in the popularity and spread of the medical system in rural areas as well as devotion of medical staff to the services. BRICS have commonly established levelby-level rural medical system，carried out various special projects and paid attention to motivate the rural medical staff. India has not only established a complete three-level network，but also produced the Rural Health Project in India and the Inland Project. In its three-level network，the Indian Ministry of Family and Welfare provides the women healthcare workers and medical inspectors with salaries，annual 3 000-rupee rents plus accident allowance，continuing medical courses and their children's priority to education. Indealing with its rural medical resources shortage，Brazil implements Family Health Project and Inland Changing Project. The former focuses on maternity and child care and disease prevention. It also gives its sufficient start-up financial support to the medical teams so the doctors and nurses are better paid than their counterparts in other public medical institutions. The latter aims to encourage private doctors to work in remote areas. The federal government will provide them with more than double pays of those of their counterparts in the urban public hospitals （Jiang and Xun，2003）. Faced up with the shortage of medical staff in remote areas，Russia began to carry out Rural Doctor Project in 2012，offering young volunteer doctors one-off one million rouble （about RMB 185 000）for building or buying houses.

Innovative medical service means

Each country is vigorously innovating its medical service means and mode. BRICS are taking their own advantages to establish the medical service mode with local characteristics. Russia，in its reform，makes an attempt on service outsourcing of some medical services. The outsourcing of ambulances makes the medical institutions more focused on their services，thus，improving their efficiency and optimizing investment in medical equipment.

The most important characteristic of Indian medical and healthcare services is the development of its medical tourism business，which is attributed to its unique advantage. The marketized Indian medical services enable its private medical institutions with advanced equipment and medics of high caliber to satisfy the needs of patients from western countries. And the treatment of some diseases can reach the world-class level. However，the medical cost is only 1/10 of that of the western countries，sometimes even 1/16 ，and 1/3 of other Asian countries. So，it is called the-third-world price and the-first-world service. In terms of medical means，besides the use of western medical equipment，the Indian traditional medicine plays a significant role. Homoeopathy，Unani，Ayur-veda and Yoga provide patients with unique service environment. So，patients enjoy the pleasure of tourism while receiving medical services at the same time （Zhang，2006）.

South Africa also pays great attention to traditional Chinese medicine. with being the first country to supervise acupuncture in a specific legal form. In terms of traditional Chinese medicine management，South Africa integrates it into the complete medical management system. Every year a qualification test for permanent license of traditional Chinese medicine doctors is held，and the Comprehensive Health Council has been established to manage traditional Chinese medicine，Indian medicine and European herbal medicine.

Brazil strictly carries out the region-by-region and level-by-level principle in managing its medical services. A patient must go to his local public community hospital to get a primary diagnosis. If necessary，doctors will transfer the diagnosis to public hospitals level by level within the four-level system until it reaches the general federal or specialized hospitals with the most advanced level and the best conditions. The system brings great benefits to the development of the basic medical services in Brazil. On one hand，it greatly improves efficiency of medical resources using，therefore putting an end to treatment of minor illness in large hospitals. On the other hand，the implementation of regional classification system makes the basic medical institutions know better about the health conditions of the local residents and about infectious diseases and epidemics timely and sufficiently，and carry out the preventive work against etiology.

Thoughts on Development of Rural Medical and Healthcare System in China

Active construction of urban and rural balance in medical security system

The free medical system in India，Brazil，Russia and South Africa makes no gap between the urban and rural areas，fully embodying the equity for all the citizens to access to medical services，which offersbeneficial experience for China to promote the integrated rural and urban medical security （Ma and Ji，2013）. In China，basic medical insurance for working urban residents，basic medical insurance for non-working urban residents，and a new type of rural cooperative medical care essentially comprise China's medical security system covering both the urban and rural residents. But the three basic medical security schemes are quite different in terms of joining people，the ways and levels of medical care financing，operation means and the reimbursement rate，causing a wide gap between urban and rural areas in terms of health service and resident security level. Although pilot reform of integrated medical insurance in both areas has started in some provinces and cities，it is still in the initial stage of exploration for lacking of national planning and guidance. To establish a unified medical system for urban and rural areas，China should make an overall plan，offer related guidance，coordinate pilot reform of medical insurance in each province，encourage qualified areas to take part in the reform，and explore a nationwide unified system of the medical insurance.

Promote reform of marketized public hospitals and development of private hospitals

Private medical institutions not only support public hospitals in basic medical services，but also effectively ensure improved efficiency of social medical services （Zhang，2007）. The rapid development of marketized private medical institutions and medical insurance greatly promotes the nationwide medical and health services in India，Brazil，Russia and South Africa. The equity of medical services for all the citizens also shows that equity of private medical service is not inconsistent with its efficiency. In China，nowadays，there are many limits to the development of private medical service. A healthy and orderly market mechanism hasn't been established and the function of government and market in the medical service is not clearly oriented. The public and private partnership in the medical service in India and Brazil achieves coordination between government and market. And different emphasises on their own medical function ensures coexistence of equity and efficiency. All these offers beneficial experience for making the medical reform policies in China （Dai，2011）. In the future of the reform，China should aim to establish a medical institution system suitable for citizens at all levels，further promoting and encouraging the development of private hospitals，and lifting the restrictions to admittance of medical institutions established by nongovernmental fund into contract hospitals. Through the competition between public and private hospitals the medical service charge can be controlled and thus medical service quality can be improved in the whole society. At the same time，the government should intensify its efforts in supervising all the medical institutions and guide healthy and prosperous development of the medical industry.

Make full use of prevention and healthcare in rural medical and healthcare system

Prevention and healthcare is an important part of rural medical and healthcare system and also a prerequisite to any disease treatments. Besides，a unified free medical service for all the citizens in the development of the basic rural medical and healthcare system，India，Brazil and South Africa all have established primary healthcare system in rural areas，which covers drinking water safety，healthcare for mothers and children，free medical examination，infectious disease preventions and disease treatments. These preventions and healthcare measures improve residents' ability to combat diseases and minimize the pressure from lacking of domestic medical resources. At present in China，the medical security mode mainly comprising critical illness insurance and comprehensive arrangement focus on solving the problem of impoverishment and hardship due to illness. But，it largely ignores the role of prevention and healthcare in medical and healthcare system. China should change the idea of the treatment being first and prevention second and adopt the mode of prevention being the first and combinationof prevention and treatment. The Chinese government should improve the medical and health conditions in rural areas through drinking water safety，toilet improvement and free medical examination，intensify publicity for prevention and health in rural areas，and vigorously encourage all the citizens to join in the publicity，so as to prevent disease from the source.

Establish effective medical supervision mechanism

In Russia，India and Brazil non-governmental or civilian organizations and other third-party management institutions are introduced into the mechanism. It will avoid the problem of lacking of government supervision and multi-channel management，in its future medical supervision and services，China should firstly make full use of the role of non-governmental and social services in medical supervision and services，so as to achieve the classified management of treatment，medicine and insurance and change oneparty mode of government supervision. Secondly，China should learn from the region-by-region and levelby-level management principle to explore two-way referral system suitable for its community hospitals. Finally，China should promote the trinity of treatment，medicine and insurance and simultaneous reforms.

Innovate medical means and encourage development of traditional Chinese medicine

With the development of medical tourism and promotion of traditional medicine in India，the Indian medical services offer very beneficial experience for innovation of medical means for each country in the world. As one of the big three world medicines，promotion of the traditional Chinese medicine development is not only to innovate Chinese medical means，but also to inherit and carry forward Chinese traditional culture. The prominent advantage of the traditional Chinese medicine development in disease prevention and healthcare and health maintenance is basically consistent with the target of basic medical security system in China. Its flexible means，definite clinic effect，relative safety of medicine taking and low cost enable it to have great innovative potential and broad space for development. While promoting the traditional Chinese medicine development，China should make clear the role of traditional Chinese Medicine in prevention and healthcare and make a plan for its development from central to regional government. While paying attention to the traditional Chinese medicine characteristics and its advantage research，China should constantly intensify publicity and promotion and focus more on the social value brought about by the development of the traditional Chinese medicine.

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F318 Document code: A Article ID: 1006-8104（2015）-01-0091-06

17 December 2014

Yang Xiu-li （1973-），female，Ph. D，associate professor，engaged in the research of social security and public policy. E-mail: yangxiuli73@126.com