On the satisfaction survey and sustainable development of ...

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On the satisfaction survey and sustainable development of NRCMS under the background of new medical reform-------from the perspective of

stakeholder of nonprofit organization

Weizhen Yu1,Guowei Wan1 1School of Management Zhejiang Shuren University, P.R. China, 310015

[email protected], [email protected]

Abstract: In this study, the author first of all builds a theoretical model about the NRCMS satisfaction which is based on the basic theory of customer satisfaction and from the perspective of stakeholder of nonprofit organization. The paper then analyzes and discusses in depth about the index variables that have influence on farmers’ satisfaction to NRCMS by validating the theoretical model against the statistics from Zhejiang Province. Finally, the paper draws a structure equation to test the satisfaction of NRCMS, shows the difficulties in its sustainable development and puts forward some countermeasures and suggestions. The paper is intended to provide theoretical guidance and reference for the healthy and sustainable development of NRCMS.

Keywords: NRCMS, Satisfaction, Stakeholder, The New Medical Reform, Nonprofit Organization

1. Introduction Since the pilot of new rural cooperative medical care (hereinafter referred to as NRCMC) in 2003, it has made remarkable achievements such as, farmers’ financial burden being reduced, the rate of seeking medical care and hospitalization being increased significantly, which has, to some extent, alleviated the dilemma of “getting poor out of illness and returning poverty out of illness”(Hu & Cai,2008). However, measured from its system structure, its implementation and its performance, there are still many factors restricting the healthy and sustainable development of NRCMC. This paper will explore its sustainable development from the perspective of stakeholder of NRCMC and

ISSN 1816-6075 (Print), 1818-0523 (Online) Journal of System and Management Sciences

Vol. 3 (2013) No. 4, pp. 29-45

Yu & Wan / Journal of System and Management Sciences Vol. 3 (2013) No.4 29-45

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nonprofit organization.

2. The Construction of Farmers’ Satisfaction Evaluation Model about NRCMC

Farmers’ Satisfaction Evaluation Model about NRCMC is based on the mature ACSI (American Customer Satisfaction Index) and it is the kind of evaluation system which is used to evaluate and improve the performance of the organization in view of its customers(Li,2005;Liu,2008). The Model not only considers the evaluation of customers’ toward the product or service, but also pay more attention to the degree that the product or service meet the needs of customers’. However, the product and service offered by NRCMC are different from the product or service provided by enterprise, so it is necessary to make some changes to the Model in this paper. Firstly, the author adds the structure variable of farmers’ awareness of the system because of the information asymmetry due to the monopoly of information controlled by the government and its organizations as well as the poor operation transparency of relevant departments, which will affect the overall satisfaction. Secondly, the author replaces the Customer Loyalty with Farmers’ Loyalty to NRCMC (Figure 1) out of the monopoly of medical security service in NRCMC which makes the customer loyalty not obvious(Liu,2008;Meng,2009).

Based on the above model, the previous research and the experience of the author in the industry, by combing the literature review, the paper puts forward the farmers’ satisfaction assessment system which specifically related to one index of level I, six indexes of level VI, five amended indexes (see Table 2), nineteen indexes of level III, seventeen amended indexes (see Table 8).

Fig. 1: Farmers’ satisfaction evaluation model

Perceived Value

Farmers’ Complaints

Farmers’ Expectancy

Farmers’ Satisfaction

Farmers’ Loyalty Farmers’

Awareness

Perceived Quality


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3. The Empirical Analysis of Satisfaction Assessment of NRCMC

3.1. The Analysis of the Stakeholders in NRCMC Through the analysis of the rights shared by the stakeholders and the model of benefit matrix, the core stakeholders in NRCMC include farmers, medical institutions, cooperative agencies and government respectively (Zhang,2008;Wang & Zhang,2008).

In this paper, the study carries out the satisfaction survey with farmers, the

cooperative agencies and the medical institutions. Taking the educational background and comprehensive ability into consideration, the method of questionnaire combined with interview is used in the investigation of farmers’ satisfaction. To the medical institutions and the cooperative agencies, depth interview is used. 3.2. Sample Selection and Survey This study is aimed to gain some knowledge of farmers’ satisfaction toward NRCMC in Zhejiang province and three pilot districts are chosen as the official targets in the survey, that is, Tongxiang, Xuyao, and Tonglu. Qualitative and quantitative researches are used in this paper. Moreover, two districts with its economy relatively backward, Kaihua in Quzhou and Jinyun in Lishui, are chosen to do in official investigation based on the author’s experience and connections.

The way of obtaining sample in this survey is called stratified cluster random selection. The first phase is to spot the interviewee. It can be subdivided into four steps. The first step is to category all of the towns in these three areas into

farmers

participate in NRCMC

government the medical institutions

the cooperative

agencies

benefits

p o w e r

high low

l o w h i g h

Fig. 2: the analysis of the stakeholders in NRCMC: power


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three types, that is, better-off towns or cities, medium development towns or cities and poor towns or cities, according to its social economic development. The second step is to choose one typical town respectively from each type of towns or cities. The third step is to determine one typical administrative village respectively according to the principle previously. Altogether there are 9 towns and 27 villages being chosen. The final step is to choose 5-6 families participate in NRCMC as investigation object. Altogether there were 150 questionnaires sent out among which 138 were effective questionnaire with an effective rate of 92%.

The second phase, after analyzing the collected data based on its reliability, validity and model fitting, the writer drew a conclusion that both the design of the questionnaire and the fitting of model were of high quality. Based on this, the write made some appropriate modifications to the questionnaire and sent out 450 of them according to the principle in the first phase. Altogether there were 429 questionnaires are effective with an effective rate of 95%. Till then, a total of 600 questionnaires were sent out with a total efficiency of 94.5%.

The third phase is to carry out the investigation officially to the Health Bureau as well as the medical agencies of NRCMC in the chosen areas. There were 9 Health Bureaus and medical agencies were interviewed in-depth with 12 designed interviewing topics. 3.3. The Test of Questionnaire and Model Path 3.3.1 The Test of Reliability to the Data The analysis of reliability by the indexes of satisfaction by SPSS (in Table 1) with the Alpha coefficient being 0.832, and the result of test to the reliability of each level of latent variables in the questionnaire shown in Table 2, both of them can tell that the design of the questionnaire is of high quality because it is believed that a coefficient reaches above 0.8 means the setting of indicator is good.

Table 1: Reliability Statistics

Cronbach's Alpha N of Items

.832 18

Table 2: the Reliability Test of Latent Variables

Latent variables number of variables Cronbach's Alpha Awareness and expectations 3 0.723 Perceived quality 5 0.741 Perceived value 3 0.886 Satisfaction 3 0.829 The trust to the system 3 0.749


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Complaints 2 0.213

We can see from Table that, except the latent variable Alpha coefficient of farmers’ compliment being as low as 0.213, the other latent variables of Alpha coefficient are all above 0.7. As the total Alpha coefficient of the table is 0.832, the data in this table is reliable. Because the Alpha coefficient of the latent variable of farmers’ complaint is below 0.7, this data is removed from the path model, that is, there are 5 latent variables and 17 measurable variables in the initial model. 3.3.2 The Analysis of Confirmatory Factor 1). the test of structure model

After testing and screening to the indicators in the assumed satisfaction index system, in addition to the removing of inappropriate variables, the satisfaction evaluation model is established, the test of structural equation includes the test of the path coefficients in latent variables and the degree of influence. The study of farmers’ satisfaction is based on ACSI index model and the result is drawn by using AMOS software (Figure 3).

Fig. 3: Model preliminary fitting path 2).analysis of model fitting degree According to the results of the exploratory factor, the verification factor

analysis is carried out by using AMOS software(Table 3). Table 3: The results of the analysis on the satisfaction verification

Evaluation index dfx2

GFI AGFI RMR NFI Validation model 1.56 0.86 0.90 0.046 0.97

We can see that the whole model is 0.80 according to Goodness Fit Index (GFI), Root Mean Residual (RMR) <0.05, x2/df<5, which all reach the

0.39

0.38

1.25 0.62

0.92

0.74

Perceived quality

Perceived value

Awareness and expectations

Satisfaction

The trust to the system

0.81


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acceptable level. This suggests that the theoretical model and the observation data the writer put forward have a high degree of fitness. Figure 4 is the structural equation model and the path according to the result.

According to Figure 4, the writer draws the structural equation of satisfaction based on path coefficients in satisfaction model as, the farmer satisfaction=0.74 of awareness and expectation+0.92 perceived quality+0.62 perceived value. 3.4. Analysis of the Survey Results 3.4.1 The Basic Situation 1). the awareness to the system

According to the survey, there are 33.3% of the participated farmers know well about NRCMC, 46.6% know a little and 16.1% have heard of the policy and 4% are unaware of it, which means that farmers have gained a better understanding of NRCMC. However, as to the specific content of many policies such as deductibles, cap lines, scope of reimbursement and ratios of the funding, the number of people who do not know the policy is less than that the number of who know the policy. It shows that, to some extent, the farmers understanding to the system is not good enough and is only confined to the superficial level. For example, how much is the insurance premium and how to pay it (Yuan,2010).

Fig. 4: The graph of the farmer satisfaction path model

1

1

f4

0.04 0.74

0.92

1

Awareness & Expectancy

Perceived Value Loyalty

B1

e4 1

B2

e5

3.01

0.51

B3

e6

4.45

0.38

B4

e7

5.57

0.49

B5

e8

2.43

1.02

A2

e9

1

0.37 A1

e10

2.25

0.44

C1

e11

1

0.57

C2

e12

3.34

-0.01

C3

e13

3.07

0.08

A3

e14

3.76

0.28

D1

e15

0.98

D2

e16

0.35

D3

e17

0.65

E1

e18

0.79

0.46

E2

e19

0.83

0.48

E3

e20

0.23

1.13

1.25

0.39 0.38

0.01 f1

0.05

f2

Satisfaction

0.87 0.90.83

0.81 0.62

f3

Perceived Quality


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2).the degree of trust to the system When asked whether they believe that NRCMC will insist to carry out, the

vast majority of farmers think that the prospect of its development is good and 76.9% of them believe that it will continue to carry out. There is no one who is sure that it is impossible for it to operate to the end, which shoes that they are confident with the development of NRCMC. As to whether the farmers will continue participating the NRCMC next year, 99.3& of them said they would continue to participate which shows the confidence of farmers’ to the system.

Through the interview with the farmers who show no confidence to NRCMC, we can find that their doubts mainly lie in four aspects. The first one is the worry that NRCMC can not last long. The second is the worry that the policy can not be realized one hundred percent. The third is the worry that cooperative medical care funds will be detained, misappropriated, even embezzled and privately shared. The fourth is the worry that there may be some people using their social relationship when doing reimbursement. During the interview, we found that few farmers know about the existence of county cooperative medical agencies even if they know they lack the trust in it. 3.4.2 The Analysis of Single Factor

1). satisfaction of participants with various health condition The result shows that, the constituent ratio of the overall satisfaction of

participants with various health condition is different (p=0.025＜0.05). It means that physical health of the participants has an influence on the overall satisfaction. According to the data, the higher satisfaction the participant families will have, the worse physical health they have; and the lower satisfaction the participant family will have, the better physical health they have. The result is shown in Table 4.

Health condition good health health ordinary poor health Very satisfied 26.6% 30.7% 38.6% 52.3% Satisfied 36.7%. 38.9% 42.6% 32.5% Common 27.8% 23.4% 12.7% 15.2% Unsatisfied 8.9% 7% 6.1% 0

Table 4: Comparison of satisfaction among participant with various health conditions 2). the satisfaction of participant with various awareness of NRCMC The result of the test of 2x for the degree of awareness to NRCMC will lead

to different constituent ratio (p=0.016﹤0.05), which can be used to test whether or not it will influence the overall satisfaction toward NRCMC.

3). the relationship of satisfaction between family with various economic status and locations


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The influence of family economic status on satisfaction has an intendancy of rising first and then deceasing. Among them, the family that suffers from serious illness and has the income of as much as 10,000 to 20,000 yuan will has the highest satisfaction, that is , as high as 4.21 (total 5 points). The tendency is reasonable. Income is positively related to the ability to bear medical risk. The lower the income is, the higher demand for health care service, and the higher lends of desire for compensation as well. However, to the family with an income as much as 20,000 yuan, the degree of satisfaction will decrease because the treatment offered by NRCMC can not meet the needs of people with relatively high income according to the principle of NRCMC that it only covers people who are suffered from serious illness; the people with a medium income have a relative high evaluation about NRCMC because they think that the medical care offered by the current system can meet their needs exactly.

This situation is similar to the relationship between the investigated areas and satisfaction. As their economic development is relatively better, the farmers in Yuyao, Tongxing in Zhejiang province are living a better life but their satisfaction about NRCMC is lower than the farmers in Tonglu. Because in these two areas, the level of medical fees is relating high, and there still exists a large gap between ideal medical care service and the existing NRCMC system. According to the survey carried in Kaihua and Jinyun, satisfaction is also high. Because the living standard in these two areas is relatively low and the expectations of farmers’ about the medical care service coincides with the service offered by NRCMC, the satisfaction of the farmers’ is high. 3.4.3 Analysis of Multiple Factors According to the importance-performance analyses put forward by Nartilla and James (1977), and with a comprehensive analysis of the importance and performance of factors that will influence the satisfaction of farmers’ participate in NRCMC, the writer draws the quadrant analysis diagram of the test of satisfaction of farmers’ participate in NRCMC with a further analysis to measurable variables.


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According to the test, the factors such as government subsidies, the range of

reimbursement, the level of payment have low influence on the satisfaction of farmers’. The possible explanation is that in recent years the performance of warfare in NRCMC is substantive follow-up, and farmers show their temporary identity to the existing management framework. Therefore, the driving force of farmers’ satisfaction is decreasing as well as its short-term elasticity. In addition, by combining calculating and the actual situation of local NRCMC, we can find that the index of variables such as the proportion of government compensation, reimbursement as well as the supervision of fund is low. All these lend to the problem of efficiency being low, financial support being serious short, and the government regulation being not in place. The low indexes has the quality of “weak elastic” to the change of satisfaction of farmers’ in a short time. Moreover, it will reduce the farmers’ trust in the sample areas toward NRCMC in the long term under the condition of raising warfare in the surrounding area which will accelerate the rate of decline of index rate of satisfaction. From the current perspective, we can see that to the level of technology and to guide farmers’ expectation reasonably, strengthen the explanation of policy in-depth, will enhance satisfaction significantly. 3.4.4 The Calculation of Satisfaction 1). the satisfaction of farmers

Awareness and expectancy staff service attitude Level of cost

Level of medical treatment complex of reimbursement

h i g h l o w

Low index high index

Table 5: The quadrant analysis diagram of the test of satisfaction of farmers


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Table 6: Farmers’ satisfaction to each index Observation variables satisfaction(%) Observation variables satisfaction(%) Whether the government information is open and enough（A1）

75.83 individual payment and government subsidies(C1) 75.6

Expected medical security service(A2)

70.7 reimbursement ratio(C2) 75.6

Expected management and service(A3) 71.3 coverage of

reimbursement(C3) 72.6

Medical convenience(B1) 86.2 total satisfaction(D1) 78.6

Medical cost(B2) 72.3 difference before and after participate in NRCMC(D2) 80.6

Staff service attitude(B3) 85.6 difference between the service expected before NRCMC(D3) 72.3

Level of medical treatment and device(B4) 73.5 the development prospect of

the system(E1) 86.4

The complexity of reimbursement(B5) 82.4

the trust to NRCMC(E2) 87.3 Whether to continue in the

future(E3) 99.3

The purpose of study the satisfaction of farmers’ in NRCMC is to calculate the satisfaction index. The paper adopts the method of factor coefficient weighed on the structure equation of satisfaction to calculate. The index of overall satisfaction is 3.976, that is, 79.52%.

2). the satisfaction survey to medical institutions and cooperative agencies of NRCMC

Through the in-depth interviews to 9 typical commune hospital in sample areas, their attitude toward NRCMC is on the whole satisfaction and supportive, which open up a new world to the development of commune hospital as well as promote the investment of medical treatment and the enhancement of medical treatment. Specific performance includes, a substantial increase outpatient services and hospital income, the decrease of debt and escape fees. At the same time, the opportunity to exchange and cooperate with high level medical units is increased. The doctors’ clinical experience has been increased which has improved their medical standard.

As an important subject in NRCMC, medical agencies’ working method and procedure will influence the other subjects’ satisfaction and interest directly. From the result of in-depth interview, the level of satisfaction is not high. The main performance include, a serious lack of staff， poor stability; vague organizational structure of agencies, poor independence; lack of financial supervision and legislation, and with no clear assessment and so on.


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4. The Dilemma of Sustainable Development of NRCMC and its Countermeasure

4.1. The Operating Situation of NRCMC and its Dilemma of Sustainable Development

After many years of practice and exploration, NRCNC has gained many achievement and experience. Coped with the newly issue of new medical reform which without question has provided a practical foundation and pointed out the direction, satisfaction of the farmers improved significantly. The research also has confirmed it. However, the contradiction between the growing medical needs of the farmers’ and the actual supply still exists, the difference between urban and rural area is still large. The farmer’s expectation from NRCMC is getting higher. The survey also shows that the growing satisfaction of farmers’ to NRCMC is with the quality of recognition of the recovery of the system. It is not the satisfaction of its “quality” but its “quantity”.

In the current implementation of NRCMC, we can see from Figure 2 that the goal that each interest group will chase is based on the principle of maximizing their interests, which will inevitably result in difference and conflict. It will in the end lead to non-cooperative game among the four subjects in NRCMC. Its specific performance include,

1).the management system has not rationalized, the organization level and management ability are not good enough;

2).the contradiction between funding and demand is apparent and the cost of financing and management is high;

3).fund management needs to be improved further; 4). the effective convergence between NRCMC and rural impoverished

medical assistance system is lack. There still exists some factors such as the potential growth of medical cost, the uneven regional development; the information system of NRCMC and so on will restrict the healthy and sustainable development of NRCMC. 4.2. The Study on the Sustainable Development to NRCMC It is shown from the survey and literature review, the core of sustainable development plight is “resource constraints” and the efficiency of resource use. Therefore, the sustainable study of NRCMC can be carried out from two respects, that is, the creative of external resources and the utilization and management of internal resources. 4.2.1 Introducing Nonprofit Organizations and Strengthening the

Independence of NRCMC


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At present, study to NRCMC is done from the perspective of the independence on the external environment. The product offered by typical nonprofit organizations of NRCMC is a quasic public product (Yuansheng, Jiang, 2008).it has been proved by both the domestic and foreign scholars that it will inevitably lead to “government failure” and “market failure” (Stiglita, J.E, 1988, Shanlian, Hu, k2002). When the organization can not obtain needed resources through the market and internalization, it must share and exchange the resources with other organizations. Therefore, in order to solve the problem of resources shortage in NRCMC, we must introduce the concept and activity of marketing and play their own advantage and function, reduce the dependence on external environmental factors, realize the interaction of internal and external factors. Its core function is to attract, utilize and allocate resources.

Enhance the independence of NRCMC. Set up independent nonprofit organization of NRCMC by taking province as unit, which will be operated independently. We should introduce management and operation of nonprofit organization, optimize the management structure and rebuild farmers’ trust. Government is the main buyers of nonprofit services. At the same time, we should introduce relevant policies, create appropriate platform to give full play to the role of market mechanism of NRCMC. In order to give full play to its functions from the outside and to create more resources, NRCMC should carry out nonprofit marketing with enterprises, organizations and individuals, which will increase the overall force of NRCMC fund and lay a good foundation for the improving of fund collection. Finally, referring to the financial system of “risk reserve” will reduce the operation cost of the system and improving the security of the system. 4.2.2 Balancing the Fairness and Efficiency of the System, Implementing

Different Standard of Funding Medical Assistance to Complement the Deficiency of NRCMC with Medical Assistance

At the same time, the farmers can choose different financing plan and medical insurance scheme such as they can enjoy different standards of medical care and compensation proportion if they pay for different programs, which will meet individual requirements. Finally, NRCMC should bring some special groups and disease into medical aid as the second line of defense to prevent farmers “getting poor out of illness and returning poverty out of illness” 4.2.3 To Strengthen the Supervision of the Medical Institutions, Reform

the Compensation Methods, Control the Unreasonable Growth of Medical Expense

The medical institution will inevitably induce demand under current health care


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system. Therefore, we should firstly, control the unreasonable growth of medical expenses; widen the gap of reimbursement proportion among different levels of medical institutions, guide farmers to “go to small hospital if they suffer from ailment, to county hospital if it is ordinary illness and to provincial hospital if it is serious illness.” Secondly, we should carry out management measures to strengthen the supervision over expense. The measure include, insisting on the payment method of “the designated medical institutions pay for the reimbursement in advance and being returned to them after being audited by management department”, and the fee management of “gross control, total prepaid, payment to individuals and setting limit expense for each treatment”. All these measures should be enforced strictly combined with practical and reasonably formulation of basic drugs and medical and diagnosis treatment directory. Thirdly, we should perfect “entry and exit” mechanism of the medical institutions. 4.2.4 To Integrate Medical Resources, Construct Medial, Exchange

Platform, Change Ideas, Strengthen the Construction of Medical Information

Integrate some similarly medical service. The integration of clinical examination in Yuyao City is worth being popularized. To set up clinical examination center with unified management and service will not only avoid the duplication of investment but also be helpful to share medical source because it is to promote the continuous improvement of basic-level medical care and . The government builds some medical exchange platform to promote the continuous improvement of basic-level medical care and realize the sharing of medical resources. It includes, using the information technology to develop remote diagnosis and treatment, setting up cooperative hospitals, adopting two-way referral system, offering outpatient services by experts regularly, receiving training at county hospital before appointed with high-level titles and so on. Meantime, the basic-level medical institutions should change their concepts. They should be active and go out to strengthen the mechanism of disease prevention in rural areas and health care system; improve the rural public health condition and health service; extend NRCMC to village and community service centers. Only by doing these can we realize the goal of everyone has the right to enjoy health care. 4.2.5 Change and Mediate the Government Function, Rationalize the

Relation Between Government and Market From the experience of developing and developed foreign countries as well as the new medical reform, the government should take all the obligations and


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responsibilities; the function of the government is irreplaceable. However, this does not mean that the government can interfere with everything by executive order.

The absence and offside of government is the two main forms of discordant. So the function and role of the government should be reconstructed.

1). Redefine the function of the government and make it return to public service. Two changes should realize, the first the change from administrative interference to legal supervision, the second is the change from economic benefit orientation to social benefit orientation.

2). Strength its functions and role-playing. As to NRCMC the government should give full play in the system design, economic support, interest coordination, legislation and so on.

3). Policy guidance and fully exploit its own initiative of NRCMC. Guided by the government, the NRCMC should create conditions and enhance it independence by introducing the operation and management mode of non- organizations and developing the nonprofit marketing to realize the interaction between the external organizations and personal. Only by doing this can we obtain more external resources and improve the supply of NRCMC.

5. Possible Innovation and Deficiency The possible innovation of this study is: 1) From the perspective of stakeholders of NRCMC, the interests of the main objectives are guided as far as possible and non-cooperative game is avoided.

2) Changed the old way of study NRCMC only from the perspective of the government function and management. Start of the perspective of nonprofit organization of NRCMC introduces the concept of nonprofit organization and marketing. It changes from previous completely dependent on external environment and resources to the transition of exerting its independence and initiative which has brought about the new way and method of fund-raising and management as well as provided new ideas for the sustainable development of NRCMC. However, there is also some deficiencies, it is not comprehensive and perfect to evaluate the satisfaction in NRCMC.

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