政府主导与引入市场机制关系初探

“十一五”规划期间是我心全面构建和谐社会的关键阶段，也是会面落实“以人为本”的科学发展现和促进杜会经济可持续发展的重要时期。在医疗卫生事业发展过程中，如何发挥政府主导作用，适当引入市场机制，促进卫生事业健康发展，全面构建和谐社会，已日益成为人们关注的话题。本文试图浅析在医疗卫生事业发展过程中．政府主导与引入市场机制的关系。     

努力营造与构建和谐医患关系促进医疗卫生行业和谐发展

医疗卫生行业的和谐包括其内部和谐与外部和谐。而医患关系的和谐是直接影响医疗服务的提供者——医院内部和谐与外部和谐的关键，更是影响医疗服务行业全面和谐发展的重点。“和谐兴医、和谐兴院”，积极主动参与构建和谐社会、构建和谐医患关系，是促进医疗卫生事业全面和谐发展的重要保证。     

企业医院面临的形势与应对策略

1 当前医疗卫生事业改革的方向 现在我国已进入全面建设小康社会的新的发展阶段，医疗卫生事业作为建设小康社会的重要组成部分，已经得到党和政府的高度重视，并摆上了重要议事日程。党的十六届六中全会通过的《中共中央关于构建社会主义和谐社会若干重大问题的决定》，高度重视卫生事业在构建社会主义和谐社会中的重要地位和作用，全面、系统地提出了卫生事业改革发展的基本原则、重大举措和目标任务。明确提出要加强医疗卫生服务，提高人民健康水平。坚持公共医疗卫生的公益性质，深化医疗卫生体制改革，强化政府责任，严格监督管理，建设覆盖城乡居民的基本卫生保健制度，为群众提供安全、有效、方便、价廉的公共卫生和基本医疗服务。在2006年10月23日中共中央政治局第三十五次集体学习会上，中共中央总书记胡锦涛强调医疗卫生事业是造福人民的事业，关系广大人民群众的切身利益，关系千家万户的幸福安康，也关系经济社会协调发展，关系国家和民族的未来。要求各级党委和政府都要切实把发展医疗卫生事业、提高人民群众健康水平放在更加重要的位置，走中国特色医疗卫生改革发展道路，加快医疗卫生事业改革发展步伐，努力满足人民群众日益增长的医疗卫生服务需求。中共广东省委关于贯彻《中共中央关于构建社会主义和谐社会若干重大问题的决定》的实施意见提出要加快医疗卫生事业发展，着力解决看病难问题。坚持公共医疗卫生的公益性质，深化医疗卫生体制改革，推进医疗机构政事分开、管办分开、医药分开、营利性与非营利性分开，加大财政对医疗卫生事业的投入，重点发展公共卫生、农村卫生、社区卫生和基本医疗服务。     

“和谐社会”与我国当前卫生服务制度的改进

一、“和谐社会”的内涵和任务 十六届六中全会明确提出了落实科学发展观，构建社会主义和谐社会，从而明确了发展依靠人民、发展为了人民、让全体人民共享改革和发展成果的和谐理念。2006年10月23日的中共中央政治局集体学习会议更是明确了建立和谐发展的医疗卫生事业是构建和谐社会的要素之一。胡锦涛总书记在会上强调，医疗卫生事业是造福人民的事业，关系广大人民群众的切身利益，关系千家万户的幸福安康，也关系经济社会协调发展，关系国家和民族的未来。胡锦涛总书记的讲话为较长时期内我国医疗卫生事业的发展指明了方向，如何在实际工作中贯彻胡锦涛总书记讲话精神，构建与和谐社会相适应的卫生服务制度，成为当今重大课题。     

我国农村医疗卫生存在的问题分析及财政对策构想

从政府缺位入手分析当前我国农村医疗卫生事业领域存在的问题，并就政府缺位原因进行解析，提出解决我国农村医疗卫生事业领域政府缺位问题的对策构想：供需兼顾，稳步推进我国医疗卫生体制改革；多方筹资，促进医疗卫生体制均衡发展；加大农村医疗卫生事业的财政支持力度；构建符合我国国情、促进农村医疗卫生事业发展的公共财政保障机制。     

义不容辞 机不可失

今年10月在我国政治生活中有两件牵动人心党心的大事，都与卫生改革与发展有关。第一件事是10月11日《中共中央关于构建社会主义和谐社会若干重大问题的决定》中用不同寻常的浓重笔墨阐述“加强医疗卫生服务，提高人民健康”。第二件事是在10月25日中共中央政治局集体学习中专题讨论医疗卫生发展时，胡锦涛总书记强调“走中国特色医疗卫生改革发展道路，加快医疗卫生事业改革发展步伐，努力满足人民群众日益增长的医疗卫生服务需求。”他特别提出“不断提高人民群众健康水平，是实现人民共享改革发展成果的重要体现，是促进社会和谐的重要举措，是党和政府义不容辞的责任。”进而强调“各级党委和政府都要把医疗卫生工作作为关心群众促进社会和谐的大事，摆上重要议事日程，不断加强和改善领导”。     

浅谈医德医风建设与构建和谐医患关系

建立良好的医患关系是医院自身发展的客观要求，而医患关系的和谐是直接影响医疗服务的提供者一医院内部和谐与外部和谐的关键，更是影响医疗服务行业全面和谐发展的重点。“和谐兴医、和谐兴院”，积极主动参与构建和谐社会、构建和谐医患关系，是促进医疗卫生事业全面和谐发展的重要保证。     

众说纷纭话"医改"--"医疗卫生体制改革"座谈会综述

近日，国务院发展研究中心推出一份题为“对中国医疗卫生体制改革的评价与建议”的调查报告（以下简称“调查报告”），认为改革开放以来，中国的医疗卫生体制改革（以下简称“医改”）是基本不成功的，这一论断犹如一石激起千层浪，引起了社会各界的巨大反响。2005年7月1日，卫生部高强部长在形势报告会上作了题为“发展医疗卫生事业，为构建社会主义和谐社会做贡献”的报告（以下简称“部长报告”），分析了卫生改革存在的问题，提出了下一步改革的思路。     

构建和谐医患关系的探索与实践

和谐医患关系是构建和谐社会的重要组成部分,也是当前医疗行业亟待解决的问题。中国医科大学附属盛京医院采取多项有效措施,构建和谐医患关系,促进医疗卫生事业的健康发展。     

对农村卫生投入情况的调查

卫生财力资源是发展农村卫生事业的重要保证，但是，改革开放以来，特别是在市场经济条件下，由于“财政分级包干”、各地经济发展不平衡和当地政府对农村卫生事业重视程度不同等原因，导致财政对农村卫生投入地区差距拉大．占财政支出的比例相对下降，使农村卫生事业的发展弱化．与广大农村居民的医疗卫生需求越来越不适应。为此，应努力开发农村卫生财力资源，以促进发展农村卫生事业。     

Public Finance Policy Strategies to Increase Access to Preconception Care

Policy and finance barriers reduce access to preconception care and, reportedly, limit professional practice changes that would improve the availability of needed services. Millions of women of childbearing age (15–44) lack adequate health coverage (i.e., uninsured or underinsured), and others live in medically underserved areas. Service delivery fragmentation and lack of professional guidelines are additional barriers. This paper reviews barriers and opportunities for financing preconception care, based on a review and analysis of state and federal policies. We describe states’ experiences with and opportunities to improve health coverage, through public programs such as Medicaid, Medicaid waivers, and the State Children's Health Insurance Program (SCHIP). The potential role of Title V and of community health centers in providing primary and preventive care to women also is discussed. In these and other public health and health coverage programs, opportunities exist to finance preconception care for low-income women. Three major policy directions are discussed. To increase access to preconception care among women of childbearing age, the federal and state governments have opportunities to: (1) improve health care coverage, (2) increase the supply of publicly subsidized health clinics, and (3) direct delivery of preconception screening and interventions in the context of public health programs.     

试论完善公立医院的补偿机制

分析了当前补偿机制存在的问题，指出补偿机制不完善，尤其是补偿金额严重不足，诱发了公立医院为生存而追逐利润，导致了“看病贵”一系列问题，有针对性地提出了改进建议。     

Appraising the financial reform in Bulgarian public health care sector: the Health Insurance Act of 1998

The public health care services in Bulgaria were deteriorating, especially during the decade of transitional process. The method of health care finance was a major reason for the poor performance of the Bulgarian public health care sector. Bulgarian policy-makers decided that an insurance-based financial mechanism could help to rescue the failing public health care services. This paper explores the social benefits and the feasibility of the insurance-based finance in the Bulgarian public health care sector. The discussion in the paper implies that, in the current conditions of economic recession, the insurance-based health care finance can not be socially beneficial for Bulgaria. Moreover, the insurance implementation seams to be unfeasible due to a lack of sufficient financial resources.     

People's willingness to pay for health insurance in rural Vietnam

Background

The inequity caused by health financing in Vietnam, which mainly relies on out-of-pocket payments, has put pre-payment reform high on the political agenda. This paper reports on a study of the willingness to pay for health insurance among a rural population in northern Vietnam, exploring whether the Vietnamese are willing to pay enough to sufficiently finance a health insurance system.

Methods

Using the Epidemiological Field Laboratory for Health Systems Research in the Bavi district (FilaBavi), 2070 households were randomly selected for the study. Existing FilaBavi interviewers were trained especially for this study. The interview questionnaire was developed through a pilot study followed by focus group discussions among interviewers. Determinants of households' willingness to pay were studied through interval regression by which problems such as zero answers, skewness, outliers and the heaping effect may be solved.

Results

Households' average willingness to pay (WTP) is higher than their costs for public health care and self-treatment. For 70–80% of the respondents, average WTP is also sufficient to pay the lower range of premiums in existing health insurance programmes. However, the average WTP would only be sufficient to finance about half of total household public, as well as private, health care costs. Variables that reflect income, health care need, age and educational level were significant determinants of households' willingness to pay. Contrary to expectations, age was negatively related to willingness to pay.

Conclusion

Since WTP is sufficient to cover household costs for public health care, it depends to what extent households would substitute private for public care and increase utilization as to whether WTP would also be sufficient enough to finance health insurance. This study highlights potential for public information schemes that may change the negative attitude towards health insurance, which this study has uncovered. A key task for policy makers is to win the trust of the population in relation to a health insurance system, particularly among the old and those with relatively low education.     

Contextual effects on health care access among immigrants: Lessons from three ethnic communities in Hawaii

Immigrant health care is the product of the dynamic interaction between societal factors and the individual's socio-economic and cultural characteristics. Our knowledge about immigrant health care, however, has been limited to individual characteristics, without paying attention to the social context in which immigrants reside. This paper explores the effects of social contexts on access to health care among recent immigrants. As a natural experiment, it compares health care experiences of three immigrant groups in Hawaii – Filipinos, Koreans, and Marshallese – who are situated in different social contexts including immigrant health policy, ethnic community, and individual networks. Through household surveys conducted between October 2005 and January 2006, information of 378 recent immigrant adults on health care access, health insurance status, socio-demographic characteristics, linguistic and cultural factors, health status, ethnic community social capital, and social networks was obtained. The results of analyses show that Marshallese respondents have better access to health care than the other two groups, in spite of their lowest socioeconomic status. The high insurance rate of the Marshallese, mainly associated with a state health policy that provides health insurance assistance for the Marshallese, is the major contributor of their greater health care access. While Filipino immigrants do not benefit from state insurance assistance, high levels of health care resources and social capital within the Filipino community enable them to have significantly better health care access than Koreans, who have higher income and educational attainment. Interestingly, the advanced family/kinship networks are associated with better levels of immigrant health care access, while the increase of co-ethnic friend networks is related to lower access to health care. This study implies that restoration of immigrants' eligibility for public health insurance assistance, development of health care resources and social capital within ethnic communities, and mobilization of immigrant networks would be effective starting points to improve health care access among immigrants.     

Adolescents and access to health care.

The developmental characteristics and health behaviors of adolescents make the availability of certain services--including reproductive health services, diagnosis and treatment of sexually transmitted disease, mental health and substance abuse counseling and treatment--critically important. Furthermore, to serve adolescents appropriately, services must be available in a wide range of health care settings, including community-based adolescent health, family planning and public health clinics, school-based and school-linked health clinics, physicians'' offices, HMOs, and hospitals. National, authoritative content standards (for example, the American Medical Association''s Guidelines for Adolescent Preventive Services (GAPS), a multispecialty, interdisciplinary guideline for a package of clinical preventive services for adolescents may increase the possibility that insurers will cover adolescent preventive services, and that these services will become part of health professionals'' curricula and thus part of routine practice. However, additional and specific guidelines mandating specific services that must be available to adolescents in clinical settings (whether in schools or in communities) are also needed. Although local government, parents, providers, and schools must assume responsibility for ensuring that health services are available and accessible to adolescents, federal and state financing mandates are also needed to assist communities and providers in achieving these goals. The limitations in what even comprehensive programs currently are able to provide, and the dismally low rates of preventive service delivery to adolescents, suggests that adolescents require multiple points of access to comprehensive, coordinated services, and that preventive health interventions must be actively and increasingly integrated across health care, school, and community settings. Unless access issues are dealt with in a rational, coordinated fashion, America''s adolescents will not have access to appropriate health services. Current efforts to minimize current health care expenditures through managed care programs inevitably conflict with efforts to deliver comprehensive preventive services to all adolescents. Use of multiple sites may not represent inadequate access to care. However, as managed care reimbursement continues to expand, school-based clinics and free-standing adolescent health programs increasingly report decreases in reimbursement without a change in demand for services. The Office of Technology Assessment study called for explicit funding and expansion of services for America''s youth; since then, a federal Office of Adolescent Health has been authorized, and, by the time this reaches print, should have received appropriations and been staffed. Dryfoos has called for expansion to nearly 5000 comprehensive programs in the coming years.(ABSTRACT TRUNCATED AT 400 WORDS)     

Transnational capital and confessional politics: the paradox of the health care system in Lebanon.

For the past two decades there has been a debate over the implementation of structural adjustment policies in the health sector of developing countries, much of it focusing on the political and economic relevance of the reform process for public health provision. However, very few studies have been able to assess the relevance of the private sector, which has had a central role in the restructuring of health services worldwide. Lebanon provides just such a case, with a predominantly private provider and the role of the state relegated to financing, with few controls over supply. This situation has ensured the systematic destruction of what remained of public provision in the 1970s. The country is now faced with one of the most expensive health services in the world, and one in which much of the population continues to live under conditions of considerable economic deprivation. The unique situation of Lebanon is maintained by its politics of confessionalism, with sociopolitical relations dominated by primordial ties of family, tribe, and kin, which does not seem to be an obstacle to the process of globalization. The authors suggest that this context reinforces the gross inequalities in access to health care; they explore the complex relationship between state, finance capital, and confessional politics in the context of health sector reform, in particular the financing of health care.     

Income-based disparities in health care utilisation under universal health coverage in Brazil, 2002–2003

Since Brazil's adoption of universal health care in 1988, the country's health care system has consisted of a mix of private providers and free public providers. We test whether income-based disparities in medical visits and medications remain in Brazil despite universal coverage using a nationally representative sample of over 48,000 households. Additional income is associated with less public sector utilisation and more private sector utilisation, both using simple correlations and regressions controlling for household characteristics and local area fixed effects. Importantly, the increase in private care use is greater than the drop in public care use. Also, income and unmet medical needs are negatively associated. These results suggest that access limitations remain for low-income households despite the availability of free public care.     

Reform strategies in Georgia and their impact on health care provision in rural areas: evidence from a household survey

The transition resulting from the break-up of the Soviet Union significantly affected the health care systems and population health status in the newly independent States. The available body of evidence suggests that contraction of public resources resulting from economic slowdown has led to the proliferation of out-of-pocket payments and private spending becoming a major source of finance to health service provision to the population. Emerging financial access barriers impede adequate utilization of health care services. Most transition countries embarked on reforming health systems and health care financing in order to tackle this problem. However, little evidence is available about the impact of these reforms on improved access and health outcomes. This paper aims to contribute to the assessment of the impact of health sector reforms in Georgia. It mainly focuses on changes in the patterns of health services utilization in rural areas of the country as a function of implemented changes in health care financing on a primary health care (PHC) level. Our findings are based on a household survey which was carried out during summer 2002. Conclusions derived from the findings could be of interest to policy makers in transitional countries. The paper argues that health financing reforms on the PHC level initiated by the Government of Georgia, aimed at decreasing financial access barriers for the population in the countryside, have rendered initial positive results and improved access to essential PHC services. However, to sustain and enhance this attainments the government should ensure equity, improve the targeting mechanisms for the poor and mobilize additional public and private funds for financing primary care in the country.