社区卫生发展及筹资与补偿政策

社区卫生服务是城市公共卫生和基本医疗服务体系的基础,是实现人人享有初级卫生保健的基本途径。为群众提供更为方便、快捷的医疗服务,同时,为大医院分流病人缓解压力。目前,社区卫生的发展面临着人、财、物的匮乏问题,解决社区卫生的筹资渠道及建立相关的补偿政策是问题的关键。     

医保政策对社区卫生服务筹资作用的潜力分析

目的探索医保政策在社区卫生服务筹资方面的作用及潜力。方法采用描述性统计分析的方法对医保在社区卫生服务利用和业务收入方面的作用及情况进行描述和比较。结果 3年间社区卫生服务利用者医疗费用支付方式的构成有显著性差异;参保居民优先选择医保定点机构的比例高于非参保居民;医保定点后社区卫生服务机构收入有所增长;启动医保补偿机构的医保收入占业务收入的比例总体呈上升趋势,但仍较低。结论参保居民就诊比例逐年上升;医保定点是影响参保居民选择就诊机构的重要因素;医保政策筹资效用显现,但仍有较大潜力。     

社会资本投资于医疗服务领域的相关政策

目前,我国开放医疗服务市场,鼓励社会资本投资于卫生领域,需要明确几个重要的相关政策:打破行政垄断,放宽市场准入;平衡卫生服务的规划指导与市场竞争的关系;在市场开放的同时,必须保证基本医疗服务需求;明确社会资本投资与卫生的重点和途径;完善分类管理政策和公立医院向民办营利性医院和非营利性医院转制的政策;鼓励公立医院的管理体制和治理结构创新;加强对医疗服务市场的监管,克服市场失灵.     

我国基层卫生机构公共筹资现状研究

目的:分析基层卫生机构公共筹资现状及业务经营能力,提出政策建议。方法:利用第四次国家卫生服务调查数据,进行定量研究。结果:仅有20%的卫生费用发生在基层卫生机构;接近10%的乡镇卫生院和40%的社区卫生服务中心没有任何财政资金支持,超过半数的村卫生室和社区卫生服务站没有获得任何补助;79%的乡镇卫生院、70%的社区卫生服务中心、37%的村卫生室和55%的社区卫生服务站业务收不抵支。结论:公共筹资对基层卫生机构覆盖的广度和支付力度亟待提高,政府卫生投入应按居民需求和卫生服务可及程度进行配置。     

Adding Home Health Care to the Discussion on Health Information Technology Policy

The potential for health information technology to improve the efficiency and effectiveness of health care has resulted in several U.S. policy initiatives aimed at integrating health information technology into health care systems. However, home health care agencies have been excluded from incentive programs established through policies, raising concerns on the extent to which health information technology may be used to improve the quality of care for older adults with chronic illness and disabilities. This analysis examines the potential issues stemming from this exclusion and explores potential opportunities of integrating home health care into larger initiatives aimed at establishing health information technology systems for meaningful use.     

MCH Functions Framework: A Guide to the Role of Government in Maternal and Child Health in the 21st Century

Objectives: At the close of the 20th century, the government's role in maternal and child health is in a state of transition. What is needed is a framework defining roles and responsibilities and guidance on how to operationalize these functions. This article presents the Maternal and Child Health (MCH) Functions Framework and discusses its value as an advocacy, planning, evaluation, and educational tool. Methods: The Johns Hopkins Child and Adolescent Health Policy Center developed the Framework in collaboration with leading public health organizations. The process entailed formulating a conceptual approach and facilitating consensus among the relevant organizations. Results: The Framework consists of three main components: (a) a list of ten essential public health services to promote maternal and child health, (b) an outline detailing program functions specific to MCH that apply to all levels of government and to all MCH populations, and (c) selected examples of local, state, and federal activities for implementing MCH program functions. Conclusions: The MCH Functions Framework can be used in advocacy, policy development, program planning, organizational assessment, education, and training. To date, it has been used by several state and local MCH agencies and in MCH education and training programs.     

Changing Definitions of Women's Health: Implications for Health Care and Policy

Objectives: To present an overview of how and why normative conceptions of women's health are changing and to discuss some implications of definitional shifts in the context of the changing U.S. health care system. Method: The paper describes the historical development of views of women's health and health care, contrasts the biomedical and biopsychosocial perspectives on women's health, and presents some evidence of challenges and opportunities for change in health care and policy. Results: While women's health has generally been equated with reproductive functions, expanded definitions focus on health through the life span and in the context of women's multiple roles and diverse social circumstances. This expanded view highlights the limitations of health services and policy based on narrower conceptions and program mandates and the need for strategies for integrated, continuous care. There is evidence of change in women's health care, including in Title V programs. Conclusions: New understandings of women's health are particularly relevant to maternal and child health programs, which are positioned to provide model approaches for improving women's health care.     

Health service providers' perceptions of barriers to tuberculosis care in Russia

The Russian Federation has witnessed a marked rise in rates of tuberculosis (TB) over the past decade. Public health TB control institutions remain broadly modelled along pre-1990 lines despite substantial programmes of investment and advocacy in implementing the World Health Organization's 'Directly Observed Treatment--short course' (DOTS) strategy. In 2002, we undertook a qualitative study to explore health care providers' perceptions of existing barriers to access to TB services in Samara Oblast in Russia. Six focus group discussions were conducted with physicians and nurses from facilities in urban and rural areas. Data were analyzed using a framework approach for applied policy research. Barriers to access to care were identified in interconnected areas: barriers associated with the health care system, care process barriers, barriers related to wider contextual issues, and barriers associated with patients' personal characteristics and behaviour. In the health care system, insufficient funding was identified as an underlying problem resulting in a decrease in screening coverage, low salaries, staff shortages, irregularities in drug supplies and outdated infrastructure. Suboptimal collaboration with general health services and social services limits opportunities for care and social support to patients. Worsening socioeconomic conditions were seen both as a cause of TB and a major obstacle to access to care. Behavioural characteristics were identified as an important barrier to effective care and treatment, and health staff favoured compulsory treatment for 'noncompliant' patients and involvement of the police in defaulter tracing. TB was profoundly associated with stigma and this resulted in delays in accessing care and barriers to ensuring treatment success.     

The Demise of Artificial Trans Fat: A History of a Public Health Achievement

Policy Points

• This article describes a strategic combination of research, advocacy, corporate campaigns, communications, grassroots mobilization, legislation, regulatory actions, and litigation against companies and government to secure a national policy to remove artificial trans fat from the US food system.
• Sharing lessons we learned can help inform policymakers, academics, policy practitioners, and students across disciplines. Some of our lessons are that system change means that all consumers benefit without the need for individual behavior change; research can both identify opportunities to improve health and support policy adoption; policy efforts can serve as public education campaigns; policy campaigns can drive marketplace changes; and engaging forward‐thinking companies can diffuse opposition to passing a policy.

ContextFor many decades, partially hydrogenated vegetable oil (PHO), the primary source of artificial trans fat in the American diet, was used widely in processed and restaurant foods. In the early 1990s, studies linked the consumption of artificial trans fat with heart disease. This article details how research and advocacy led to eliminating artificial trans fat from the US food supply.MethodsWe synthesized published studies of the health impact of trans fat, the legislative history of state and local trans fat bills, the Food and Drug Administration''s (FDA) regulatory docket on trans fat labeling and its declaration that PHOs are no longer Generally Recognized as Safe (GRAS), and our own files, which included strategy documents, notes from meetings with the FDA staff, correspondence between advocates and the FDA, fact sheets, press releases, news clips, and other materials.FindingsThis history of trans fat provides insights into policy strategy and advocacy best practices that resulted in the removal of trans fat from food in the United States, preventing an estimated 50,000 premature deaths a year. The lessons we learned are that system change benefits all consumers without the need for individual behavior change; research can both identify opportunities to improve health through policy and support policy adoption; policy campaigns can serve as public education campaigns; policy can drive changes to products and the marketplace; and engaging forward‐thinking companies can help diffuse opposition to passing a policy. Securing this policy required the persistence of scientists and health advocates in first discovering the risks and then using the science to secure policies to mitigate the identified harm.ConclusionsAn understanding of the tactics used to help attain the targeted policies and how challenges were addressed (such as through communications, leveraging an expanding research base and expert reports, showing that a national policy was feasible through voluntary corporate changes and state and local policy, and litigation against companies and government agencies) may provide a model for scientists, students, advocates, and policymakers. We hope this account will inform efforts to address other public health challenges, such as the current threats of excessive exposure to sodium and added sugars, which persist in the US food system.     

The Anticipated Future of Public Health Services Post COVID-19: Viewpoint

In March 2020, the World Health Organization declared COVID-19 as a global pandemic. The COVID-19 pandemic has affected various public health functions and essential services in different ways and magnitudes. Although all countries have witnessed the effect of COVID-19, the impact differed based on many factors including the integrity and resiliency of the countries’ health systems. This paper presents opinions and expectations of the authors about the anticipated changes in the future of public health at the global, regional, and national levels. The viewpoint is based on the current efforts and challenges that various stakeholders have carried out to control COVID-19 and the contribution from the literature on the future of public health. Numerous agencies and actors are involved in the fight against COVID-19 with variations in their effectiveness. The public health services showed weaknesses in most of the countries, in addition to the lack of adequate curative medicine settings. The pandemic highlighted the need for better governance and stronger and more resilient health systems and capacities. The COVID-19 experience has also emphasized the importance of coordination and collaboration among the countries and stakeholders. The COVID-19 pandemic might lead to a wide discussion to improve international and national approaches to prepare for and respond to similar events in terms of preparedness and response mechanisms and tools. Public health will not be the same as before COVID-19. New health priorities, approaches, and new agendas will be on the table of the global platforms and initiatives. More investment in research and technology to meet the demand for new vaccines and medicines, innovative methods like distance learning and working, more respect and remuneration to health professionals, and normalization of the public health and social measures that were induced during the COVID-19 pandemic are expected to be seen in future.     

Pathways to the Use of Health Services Research in Policy

Objective. To apply social science theory so as to define more explicitly the pathways that influence policy makers' use of health services research.
Methods. The analysis builds on a literature review and the author's observations. It identifies important social science concepts relevant to use of research in policy and organizational decision making. It integrates and expands upon existing frameworks to differentiate and analyze 10 pathways that can lead to the use of health services research by policy makers.
Principal Findings. The process through which research is applied involves many factors, only some of which are amenable to influence by researchers. Within these constraints, multiple pathways can drive research use; no one of these is likely to perform better in all circumstances. Successful uptake is more likely when these pathways cause findings to be converted into messages meaningful to policy makers. Various intermediaries play an important role in creating effective pathways, while users also can influence them.
Conclusions. The pathways open up what too often is an unexplored "black box" that mediates between health services research and its use by policy makers. Such pathways can help stakeholders to bridge different perspectives in ways that strengthen the possibility that effective research will be supported and used.     

The Return on Investment in Health Care: From 1980 to 2000

OBJECTIVE: To estimate the return on US investment (ROI) in overall health as well as four specific conditions. METHODS: The study utilized three distinct approaches to "triangulate" the evidence as related to ROI in health care: 1) an estimation of the average ROI in additional health-care service expenditures in the United States for the year 2000 compared with the year 1980, based on US summaries of health expenditures and health outcomes; 2) an estimate of the ROI in Medicare services for the period from 1985 to 2000 for treatment of heart attack, stroke, type 2 diabetes, and breast cancer, based on National Long-term Care Survey data and Medicare claims; and 3) an estimate of the ROI for selected major treatment innovations for the same four conditions during the period from 1975 to 2000. RESULTS: We calculated that each additional dollar spent on overall health-care services produced health gains valued at Dollars 1.55 to Dollars 1.94 under our base case assumptions. The return on health gains associated with treatment for heart attack, stroke, type 2 diabetes, and breast cancer were Dollars 1.10, Dollars 1.49, Dollars 1.55, and Dollars 4.80, respectively, for every additional dollar spent by Medicare. The ROI for specific treatment innovations ranged from both savings in treatment costs and gains in health to gains in health valued at Dollars 1.12 to Dollars 38.00 for every additional dollar spent. Conclusion: The value of improved health in the US population in 2000 compared with 1980 significantly outweighs the additional health-care expenditures in 2000 compared with 1980.     

社区卫生服务改革的可持续发展与政策建议

通过对上海市长宁区社区卫生服务综合配套改革运行过程及社区卫生服务发展效率、质量的研究,提出了对社区卫生服务可持续发展的政策建议,即进一步巩固和完善医疗保险预付制、进一步加强社区卫生服务能力建设以及推进以社区卫生服务为基础的城市新型医疗服务体系构建。     

Integrating Children's Health Services: Evaluation of a National Demonstration Project

Objectives: Increasingly, the public and private sectors are turning to service integration efforts to reduce, if not eliminate, barriers to needed care created by categorical programs. In 1991, the Robert Wood Johnson Foundation established a new national demonstration project, called the Child Health Initiative, intended to test the feasibility of developing mechanisms at the community level to coordinate the delivery of health services and to pay for those services through a flexible pool of previously categorical funds. This article presents the findings of an independent evaluation of the Child Health Initiative. Method: The evaluation utilized a combination of qualitative methods to assess and describe the experiences of the communities as they developed and implemented integrated health services. It used a repeated measures design involving two site visits and interim telephone interviews, as well as review of documents. Results: Overall, the demonstration project achieved mixed success. Both care coordination and the production of community health report cards were found to be achievable within the relatively short life of the foundation grant. However, many sites experienced significant delays in the production of report cards and implementing care coordination plans because the sites largely did not benefit from the successful models already in existence. Little clear progress was made in implementing the decategorization component of the project. Sites experienced difficulties due to lack of previous experience with this new undertaking, the inability to secure active cooperation from local, state, and federal agencies, the relatively short duration of the project, and other factors. Conclusions: A number of lessons were learned from this project that may be useful in future decategorization experiments, including (1) a clear understanding of the concept and its applications among all parties is essential, (2) high-level political commitments to the effort are needed between all levels of government, (3) adequate technical assistance should be provided to surmount technical considerations in establishing a workable approach to decategorization, and (4) decategorization and service integration efforts should focus on both the health and social sectors.     

Upstream Policy Changes to Improve Population Health and Health Equity: A Priority Agenda

Policy Points

• Upstream factors—social structures/systems, cultural factors, and public policy—are primary forces that drive downstream patterns and inequities in health that are observed across race and locations.
• A public policy agenda that aims to address inequities related to the well-being of children, creation and perpetuation of residential segregation, and racial segregation can address upstream factors.
• Past successes and failures provide a blueprint for addressing upstream health issues and inhibit health equity.