卫生资源优先次序分配的影响因素研究:基于重庆卫生行政人员态度调查

目的:摸清重庆卫生行政人员关于卫生资源优先次序分配的影响因素.方法2013年2月-2014年2月,通过likert问卷调查重庆市卫生行政人员关于卫生资源优先次序分配的态度.结果:摸清卫生资源优先次序分配相关程序公平、决策水平、利益相关方、政策行政环境四个方面的影响因素.结论:被调查对象对公众参与赋权仍有顾虑,对市场力量介入持更宽容态度,而对媒体、学术力量、公众的重视程度有待加强,被调查者自身的决策水平尚待提高;卫生行政环境有利于展开卫生资源优先次序分配.     

基于合理问责框架的卫生政策制定公平性分析——以新医改方案为例

由于卫生资源的有限与卫生需求增长之间的矛盾,近年来卫生政策研究的焦点之一是通过资源分配的优先次序研究,帮助决策者对卫生资源进行有效和公平的分配。从上世纪90年代末开始,合理问责框架逐渐成为保障卫生优先次序分配程序公平性的主导范式之一。本文利用合理问责框架,以新医改政策制定为例对卫生政策制定的公平性进行分析,认为关联、修正/上诉两个条件的公平性较差,公开、执行两个条件从形式上而言具有较好的公平性,但是就实质公平而言仍有可努力的空间。建议加强决策过程的透明公开,实现各利益相关方的参与赋权;提高政府决策能力并落实政治承诺;最后提出建构程序公平的四个路径。     

稀缺卫生资源微观分配的研究

稀缺卫生资源包括稀有的卫生资源或者紧缺的卫生资源.稀缺卫生资源的微观分配是指将稀缺资源在不同的病人间分配,即选取哪些个体作为接受稀缺卫生资源的对象.如何使用稀缺卫生资源,澳大利亚、英国、巴西等国家制定了相关的伦理原则和分配制度.在我国,坚持稀缺卫生资源微观分配的相关伦理原则,建立符合我国实际的分配制度,将对推进我国卫生事业的公平性起到极大的促进作用.     

再谈卫生保健市场中市场与政府的作用

SARS的防治过程中,尤其是农村的防治过程中暴露了农村卫生医疗资源和医疗服务体系的缺陷,这些问题与政府与市场在卫生保健市场中的作用密切相关。从卫生经济学理论来看,要综合考虑竞争、需求、供给和再分配4个方面的问题,才能制定出协调、有效的卫生经济政策,而不是“头痛医头、脚痛医脚”的权宜之计。传统卫生经济学理论阐述了市场缺陷、市场失灵和政府失灵等理论问题,但未能进一步阐明市场在卫生保健的哪些领域中可以发挥作用,以及哪些领域需要依赖于政府,也没有探讨市场与政府共同工作以便形成更好的卫生政策的方法。为使卫生改革系统地实施,有必要对政府和市场的作用等基本的问题进行重新思考。分析市场与政府相比在卫生保健中促进效率方面的相对优势,在分配健康与卫生服务中与达到公平的备择方法、市场与政府如何共同作用以取得更优的卫生保健系统3个与卫生政策密     

新时代卫生资源分配决策的价值理性及规范价值探讨

卫生资源的短缺和浪费现象较为普遍，医疗控费及其管控措施也会不断被强化。卫生资源分配不单是需要借助经济学方法提供决策证据，更应重视价值判断讨论资源分配决策的"应然"问题，不同价值观的偏好深刻影响宏观卫生资源分配制度的设计。在健康中国的国家战略执行新时期，有必要探讨影响卫生分配决策的主流价值观及其决策伦理价值规范，发展适合本土卫生发展的价值观，重视基于价值的卫生服务体系设计，有助于展开负责任的决策行为和政策执行。     

卫生经济学在临床应用的价值综述

卫生经济学是关注有效分配医疗资源的经济学科,主要是通过可用的资源使社会对健康的收益最大化。在对医疗服务需求不断增加和医疗资源配置有限的情况下,卫生经济学在临床的应用越来越被重视,甚至在临床决策方面也逐渐发挥重要作用。通过介绍卫生经济学,并讨论其与临床应用的相关性,有助于临床医生理解卫生经济学与其医疗实践之间的联系,以及临床决策如何反映医疗资源配置。     

第三讲 卫生经济学在农村卫生工作中的应用

卫生经济学是运用经济学原理和方法研究卫生系统的经济关系和经济活动 ,以求实现卫生资源最优的筹集、分配、使用 ,使卫生资源发挥最佳绩效的一门应用经济科学。在我国 ,卫生经济学是卫生改革的产物。从中国卫生经济学在我国学术界开始出现到今天 ,只有短短的 2 0年。在这 2 0年当中 ,卫生经济学对我国卫生政策的制定和实施 ,对我国卫生改革的创新和不断深化 ,发挥了十分重要的积极作用。本讲由三个部分组成。第一部分介绍卫生经济学基本知识 ;第二部分讲授卫生工作中日常应用得比较多亦及比较重要的卫生经济学原理和方法。第三部分专门讨论…     

急性呼吸道传染病疾病负担及评价方法研究进展

急性呼吸道传染病发病急、传播快,社会影响大,可造成社会经济的重大损失。其防控需要政府较大的卫生投入。疾病负担研究能够为政府的卫生决策提供科学依据,确定不同传染病防控的卫生投入力度和优先次序。为此,本文对急性呼吸道传染病的疾病负担及其评价方法进行综述。     

非政府组织在全球健康治理中的作用研究

全球健康体系正在经历变革和更新,从而带来全球健康参与者的重大转变。非政府组织(Nongovernmental organization,NGO)作为全球健康体系中的一个关键参与者和决策者,具有全球健康治理的丰富经验,可以为中国参与全球健康决策与治理提供系统性的经验。本文旨在研究NGO在全球健康领域中的作用。结果发现,NGO在全球健康领域中的作用可以总结为四个方面:倡导、实施、支持和社区动员,但同时NGO也会给全球健康治理带来一些潜在的风险,如某些NGO所代表的国外组织或政府的利益和本国利益产生冲突;NGO组织可能会吸引当地卫生官员和技术人员加入,从而削弱了本国卫生人力和卫生体系;捐助者驱动的资助模式可能不能完全用于国家健康需要的优先领域。中国和中国NGO在借鉴经验的同时,也要合理规避这些风险。     

卫生资源的四次分配机制与分配性公平卫生改革模式的战略思考

卫生资源既是卫生服务体系的重要组成部分,又是健康照顾体系运作的物质基础。卫生资源的分配机制与分配原则至关重要,关系国家、市场和医疗卫生机构之间的关系模式。传统分配理论体系侧重市场初次分配和国家的二次分配,无法充分反映卫生资源分配的现状,从而提出卫生资源四次分配机制和分配原则,讨论分配性公平卫生改革模式的理论政策。     

Managing Healthcare Budgets in Times of Austerity: The Role of Program Budgeting and Marginal Analysis

Given limited resources, priority setting or choice making will remain a reality at all levels of publicly funded healthcare across countries for many years to come. The pressures may well be even more acute as the impact of the economic crisis of 2008 continues to play out but, even as economies begin to turn around, resources within healthcare will be limited, thus some form of rationing will be required. Over the last few decades, research on healthcare priority setting has focused on methods of implementation as well as on the development of approaches related to fairness and legitimacy and on more technical aspects of decision making including the use of multi-criteria decision analysis. Recently, research has led to better understanding of evaluating priority setting activity including defining ‘success’ and articulating key elements for high performance. This body of research, however, often goes untapped by those charged with making challenging decisions and as such, in line with prevailing public sector incentives, decisions are often reliant on historical allocation patterns and/or political negotiation. These archaic and ineffective approaches not only lead to poor decisions in terms of value for money but further do not reflect basic ethical conditions that can lead to fairness in the decision-making process. The purpose of this paper is to outline a comprehensive approach to priority setting and resource allocation that has been used in different contexts across countries. This will provide decision makers with a single point of access for a basic understanding of relevant tools when faced with having to make difficult decisions about what healthcare services to fund and what not to fund. The paper also addresses several key issues related to priority setting including how health technology assessments can be used, how performance can be improved at a practical level, and what ongoing resource management practice should look like. In terms of future research, one of the most important areas of priority setting that needs further attention is how best to engage public members.     

The political dimension in health care technology assessment programs

This article considers technology assessment (TA) to be a comprehensive form of policy research. Technology assessment must then have a relation to policy-making; in the area of health care, TA must relate to such political decisions as resource allocation. Since policies are determined politically, i.e., by factors such as power and influence, technology assessment is, or should be, part of a political process. Technology assessment seems to be developing predominantly as a technical and professional activity, carried out in centers with no relation to the policy-making process. While the impact of technology on health, as well as such broader impacts as those on financial costs, is a key concern, political considerations and political decision-making must always be an important dimension in health care TA.     

Pakistan's maternal and child health policy: analysis, lessons and the way forward

An estimated 400,000 infant and 16,500 maternal deaths occur annually in Pakistan. These translate into an infant mortality rate and maternal mortality ratio that should be unacceptable to any state. Disease states including communicable diseases and reproductive health (RH) problems, which are largely preventable account for over 50% of the disease burden. The analysis of Pakistan's maternal and child health (MCH) and family planning (FP) policy covers the period 1990-2002, and focuses on macroeconomic influences, priority programs and gaps, adequacy of resources, equity and organizational aspects, and the process of policy formulation. The overall MCH/FP policy is well directed. MCH/FP has been a priority in all policies; resource allocation, although unacceptably low, has substantially increased during the last decade; and there is a progressive shift from MCH to the reproductive health (RH) agenda. Areas in need of improvement include greater use of evidence as a basis for policy; increased priority to nutrition programs, measures to reduce neonatal and perinatal mortality, provision of emergency obstetric care, availability of skilled birth attendants, and a clear policy on integrated management of childhood illnesses. Enhanced planning capacity, development of a balanced human resource, improved governance to reduce staff absenteeism and frequent transfers, and a greater role of the private sector in the provision of services are some organizational aspects that need the governments' consideration. There are several lessons to be learnt: (i) Ministries of Health need sustained stewardship and well-documented evidence to protect cuts in resource allocation; (ii) frequent policy announcement sends inappropriate signals to managers and weakens on-going implementation; (iii) MCH/FP policies unless informed by evidence and participation of interest groups are unlikely to address gaps in programs; (iv) distributional and equity objectives of MCH/FP be addressed while setting overall national goals; (v) institutional capacity is a vital ingredient in translating MCH/FP policies into effective services. The suggested strategic directions emphasize, among others, the need for a comprehensive MCH/FP framework; strengthened stewardship in ministry of health, cost-effective strategies to address the gaps identified and doubling of the public sector resource allocation to MCH/FP over the next 5 years. The ability to ensure delivery of quality health services remains the biggest challenge in the Pakistani health sector. Unless sound policies are backed by well-functioning programs they are likely to become a victim of poor implementation.     

Trends in health care delivery. Where do they lead?

There is a growing coalescence of preventive and curative services, of in-patient and ambulatory services and of diversified specialist services, all tending to be financed increasingly from single comprehensive funding mechanisms. There is also an increasing tendency to view the totality of health care facilities as a single community resource, with “community” crossing traditional governmental boundaries as one views efforts in health planning. These forces tend to indicate a new means of organization of health services and a new role for official health agencies. One possible organizational pattern is described, resulting in decentralizing those services of a personal nature to community-based comprehensive health care centers which would deliver the totality of services on a coordinated basis, leaving to central health authorities the functions of health surveillance, planning and resource allocation, standard setting and environmental protection.     

国外卫生资源分配的公众参与研究：基于卫生优先级制定理论的思考

卫生资源合理分配是卫生政策制定的难题之一,卫生优先级制定理论为此提供解决方法。优先级制定所涉及的公众参与理论研究,将有助于增强我国卫生资源分配政策制定的透明度和有效性。     

政治体制对政府医疗卫生支出及健康产出的影响综述

大多数发展中国家的政府医疗卫生支出及健康产出长期处于较低水平,与发达国家有较大差距。这种差距并不能仅仅由经济因素解释,政府主导了卫生资源的分配,因此分析理性政府在公共资源分配中的激励问责机制尤为重要。本文分析了政治体制对政府提供医疗卫生服务的激励问责机制,综述了近年来有关政治体制影响政府医疗卫生支出及健康产出的实证研究。大量研究结果表明与非民主政治体制相比,民主政治体制在增加政府医疗卫生支出、提高健康产出方面有显著的积极作用。     

Community-based DOTS and family member DOTS for TB control in Nepal: costs and cost-effectiveness

Background

Decisions regarding the allocation of available resources are a source of growing dissatisfaction for healthcare decision-makers. This dissatisfaction has led to increased interest in research on evidence-based resource allocation processes. An emerging area of interest has been the empirical analysis of the characteristics of existing and desired priority setting processes from the perspective of decision-makers.

Methods

We conducted in-depth, face-to-face interviews with 18 senior managers and medical directors with the Vancouver Island Health Authority, an integrated health care provider in British Columbia responsible for a population of approximately 730,000. Interviews were transcribed and content-analyzed, and major themes and sub-themes were identified and reported.

Results

Respondents identified nine key features of a desirable priority setting process: inclusion of baseline assessment, use of best evidence, clarity, consistency, clear and measurable criteria, dissemination of information, fair representation, alignment with the strategic direction and evaluation of results. Existing priority setting processes were found to be lacking on most of these desired features. In addition, respondents identified and explicated several factors that influence resource allocation, including political considerations and organizational culture and capacity.

Conclusion

This study makes a contribution to a growing body of knowledge which provides the type of contextual evidence that is required if priority setting processes are to be used successfully by health care decision-makers.     

职业卫生示范企业创建实践中职业卫生投入分析

目的探讨用人单位职业卫生投入与职业卫生工作水平的关系。方法根据用人单位职业病防治指南及评估工具,通过制度创建职业卫生示范企业的方案和程序文件,企业开展基线评估、针对评估发现的问题采取改进措施、再经专家审议、现场评审与验收等程序,组织企业创建职业卫生示范企业。本研究建立了企业基本情况数据库、示范企业评分结果数据库,并应用SPSS15．0、EpiData3．1软件,使用相关分析方法、一般线性模型等方法进行资料统计与分析。结果参加现场评审的64家企业①人均职业卫生经费排在前三位的行业是核工业、电力和建材,人均费用分别是15953元,8645元,6020元;②职业接触者人均职业卫生费用排在前三位的行业是建材、核工业和电力,人均费用分别是28117元,26469元,25139元;③职业卫生投入占总产值百分比排在前三位的行业是有色、建材和石油,分别是1．45％、1．37％、1．05％;④职业卫生投入占总利税前三位的是化工、有色和航空,分别是38．00％、28．91％、28．76％;⑤职业接触者人均职业卫生费用也与综合得分有线性关系,费用投入高者得分亦高。结论①职业卫生工作水平和职业卫生投入有关,职业接触者人均职业卫生费用是敏感指标,投入越高职业卫生工作水平越高;②开展职业卫生投入、疾病负担的研究,筛查敏感指标,对企业有效分配职业卫生资源具有重要指导意义;③通过研究分析职业卫生政策、措施的成本和效果、筛选优先重点控制领域,对指导国家职业卫生资源的有效合理分配具有重要意义。     

Health care priority setting: principles, practice and challenges

BACKGROUND: Health organizations the world over are required to set priorities and allocate resources within the constraint of limited funding. However, decision makers may not be well equipped to make explicit rationing decisions and as such often rely on historical or political resource allocation processes. One economic approach to priority setting which has gained momentum in practice over the last three decades is program budgeting and marginal analysis (PBMA). METHODS: This paper presents a detailed step by step guide for carrying out a priority setting process based on the PBMA framework. This guide is based on the authors' experience in using this approach primarily in the UK and Canada, but as well draws on a growing literature of PBMA studies in various countries. RESULTS: At the core of the PBMA approach is an advisory panel charged with making recommendations for resource re-allocation. The process can be supported by a range of 'hard' and 'soft' evidence, and requires that decision making criteria are defined and weighted in an explicit manner. Evaluating the process of PBMA using an ethical framework, and noting important challenges to such activity including that of organizational behavior, are shown to be important aspects of developing a comprehensive approach to priority setting in health care. CONCLUSION: Although not without challenges, international experience with PBMA over the last three decades would indicate that this approach has the potential to make substantial improvement on commonly relied upon historical and political decision making processes. In setting out a step by step guide for PBMA, as is done in this paper, implementation by decision makers should be facilitated.     

Qualitative methodologies in health-care priority setting research

Priority setting research in health economics has traditionally employed quantitative methodologies and been informed by post-positivist philosophical assumptions about the world and the nature of knowledge. These approaches have been rewarded with well-developed and validated tools. However, it is now commonly noted that there has been limited uptake of economic analysis into actual priority setting and resource allocation decisions made by health-care systems. There seem to be substantial organizational and political barriers. The authors argue in this paper that understanding and addressing these barriers will depend upon the application of qualitative research methodologies. Some efforts in this direction have been attempted; however these are theoretically under-developed and seldom rooted in any of the established qualitative research traditions. Two such approaches - narrative inquiry and discourse analysis - are highlighted here. These are illustrated with examples drawn from a real-world priority setting study. The examples demonstrate how such conceptually powerful qualitative traditions produce distinctive findings that offer unique insight into organizational contexts and decision-maker behavior. We argue that such investigations offer untapped benefits for the study of organizational priority setting and thus should be pursued more frequently by the health economics research community.