直接举办还是购买卫生服务：相关理论与政策问题探讨

政府购买卫生服务还是政府举办医疗机构直接提供卫生服务,这是学术界和政策制定者关注和争论的焦点问题之一。本文从这两项政策的具体内涵入手，比较两种干预方式的具体形式、理论基础和实践经验，分析购买卫生服务中必须解决的为谁购买、购买什么、从何处购买、如何购买、以何种价格购买以及谁是购买者等基本问题，并根据现阶段我国医疗卫生市场的发展状况进行政策取舍，得出了基本结论：二者都是政府实现卫生责任的方式，具有不同的适用范围和条件；当前应以政府直接举办医疗机构为主要形式，当务之急是完善卫生经费的拨款方式，加强绩效考核，提高资金的使用效率。     

Hospital support services and the impacts of outsourcing on occupational health and safety

Background: Outsourcing labor is linked to negative impacts on occupational health and safety (OHS). In British Columbia, Canada, provincial health care service providers outsource support services such as cleaners and food service workers (CFSWs) to external contractors.

Objectives: This study investigates the impact of outsourcing on the occupational health safety of hospital CFSWs through a mixed methods approach.

Methods: Worker’s compensation data for hospital CFSWs were analyzed by negative binomial and multiple linear regressions supplemented by iterative thematic analysis of telephone interviews of the same job groups.

Results: Non-significant decreases in injury rates and days lost per injury were observed in outsourced CFSWs post outsourcing. Significant decreases (P < 0.05) were observed in average costs per injury for cleaners post outsourcing. Outsourced workers interviewed implied instances of underreporting workplace injuries.

Conclusions: This mixed methods study describes the impact of outsourcing on OHS of healthcare workers in British Columbia. Results will be helpful for policy-makers and workplace regulators to assess program effectiveness for outsourced workers.     

Neuropsychological evidence for a competitive bias against contracting stimuli

Two experiments examined extinction to stimuli presented either with contracting or expanding motion. Experiment 1 used solid shapes which either increased or decreased in size rapidly, consistent with looming motion. Experiment 2 employed random dots so that stimulus size was not confounded with type of motion. In both experiments extinction was modulated by the type of motion presented, with extinction most evident when a contracting object was in the weaker visual field. In addition, in Experiment 2 there was evidence for grouping modulating extinction, when there were looming stimuli in both fields. The results suggest that looming motion is a powerful determinant of stimulus salience in selective attention.     

What can transaction costs tell us about governance in the delivery of large scale HIV prevention programmes in southern India?

This paper aims to understand the transaction costs implications of two different governance modes for large scale contracting of HIV prevention services to non-governmental organisations (NGOs) in 2 states in India as part of the National AIDS Control Programme between 2001 and 2003. Interviews at purposively selected case study NGOs, contracting agencies and key informants as well as document review were used to compile qualitative data and make comparisons between the states on five themes theoretically proposed to shape transaction costs: institutional environment, informational problems, opportunism, scale of activity and asset specificity (the degree to which investments made specifically for the contract have value elsewhere). The State AIDS Control Society (SACS) in state Y used a management agency to manage the NGO contracts whereas the SACS in state X contracted directly with the NGOs. A high level of uncertainty, endemic corruption and weak information systems served to weaken the contractual relationships in both states. The management agency in state Y enabled the development of a strong NGO network, greater transparency and control over corrupt practises than the contract model in state X. State X's contractual process was further weakened by inadequate human resources. The application of the transaction cost framework to contracting out public services to NGOs identified the key costs associated with the governance of HIV prevention services through NGO contracts in India. A more successful form of relational contract evolved within the network of the contract management agency and the NGOs. This led to improved flows of information and perceived quality, and limited corrupt practises. It is unlikely that the SACS on its own, with broader responsibilities and limited autonomy can achieve the same ends. The management agency approach therefore appears to be both transaction cost reducing and better able to cope with the large scale of these contracting programmes.     

Privatization of social services: quality differences in Swedish elderly care

One of the major policy trends in recent decades has been the privatization of social services. This trend has also reached Sweden, a welfare state with health care and social service sectors that previously had almost no private providers. One of the most affected areas is elderly care, i.e. home-help services and residential care provided to citizens older than 65 years, where the proportion of private providers increased from 1% in 1990 to 16% in 2010. The ongoing privatization in Sweden and many other countries has raised important questions regarding the consequences of this policy transformation. In this paper, we present a cross-sectional study comparing the quality of services in private and public elderly care. Using statistics from 2007 displaying a variety of quality dimensions covering over 99% of all elderly care residents in Sweden, we were able to show that privatization is indeed associated with significant quality differences. Structural quality factors such as the number of employees per resident was significantly smaller (-9%) in private elderly care. On the other hand, the proportion of residents participating in the formulation of their care plan (+7%), the proportion of elderly with a reasonable duration between evening meal and breakfast (+15%), and the proportion of elderly offered different food alternatives (+26%) were significantly in favour of private contractors. Our conclusion is that private care providers seem to emphasize service aspects rather than structural prerequisites for good care.     

The deleterious consequences of privatization and outsourcing for hospital support work: the experiences of contracted-out hospital cleaners and dietary aids in Vancouver, Canada

This article is based on the findings of the Hospital Support Workers Study, which includes in-depth interviews with 70 hospital housekeepers and dietary aids in Vancouver, British Columbia, Canada. As a result of provincial government legislation in 2003, all hospital-based support work in the Vancouver region was privatized and contracted out to three multinational corporations. The outsourcing of hospital support services is part of a larger global trend toward neoliberal policy reform in health care. This article presents the perceptions of hospital support workers about the consequences of contracting out on their work conditions, training, turnover rates and other issues that directly affect their quality of work and have important implications for patient health and well-being. The findings suggest serious negative consequences for the health care system as a result of the privatization and contracting out of hospital support services.     

六种八肽胆囊收缩素（CCK－8）类似物对豚鼠胆囊收缩活性的测定

测定了六种ＣＣＫ－８类似物对豚鼠胆囊肌条的收缩活性，在Ｅ０５０值的基础上与ＣＣＫ－８标准品比较。结果显示，其活性顺序为：类似物（２）＞类似物（１）＝ＣＣＫ一８标准品＝类似物（３）＞类似物（４），类似物（５）及类似物（６）在剂量高达１０－７ｍｏｌ／Ｌ时仍未显示其活性。实验表明：脱去Ｎ－端氨基的ＣＣＫ一８类似物即Ｓｕｃ－ＣＣＫ－７［类似物（２）］较ＣＣＫ一８活性明显增加，有临床价值，在类似物（３）中，甲硫氨酸被正亮氨酸取代，活性可完全保留，类似物（４）因ＧＬＹ２９被Ｄ－ＡＬａ取代，活性显著降低，但仍可表现其激动剂性质，当ＧＬＹ２９被β－ＡＬａ取代时，即类似物（５）失去了收缩胆囊的活性。     

合同能源管理在绿色医院节能管理中的应用

结合上海市医院能耗现状,分析了当前医院能源管理所面临的困境,阐述绿色医院高效后勤对医院能源管理提出的要求,探讨以合同能源管理为核心的一体化节能改造和运行托管模式,以及实施过程中需要注意的环节,为绿色医院高效运行和可持续发展提供科学的能源管理途径.     

Data Sharing of Imaging in an Evolving Health Care World: Report of the ACR Data Sharing Workgroup,Part 2: Annotation,Curation, and Contracting

A core principle of ethical data sharing is maintaining the security and anonymity of the data, and care must be taken to ensure medical records and images cannot be reidentified to be traced back to patients or misconstrued as a breach in the trust between health care providers and patients. Once those principles have been observed, those seeking to share data must take the appropriate steps to curate the data in a way that organizes the clinically relevant information so as to be useful to the data sharing party, assesses the ensuing value of the data set and its annotations, and informs the data sharing contracts that will govern use of the data. Embarking on a data sharing partnership engenders a host of ethical, practical, technical, legal, and commercial challenges that require a thoughtful, considered approach. In 2019 the ACR convened a Data Sharing Workgroup to develop philosophies around best practices in the sharing of health information. This is Part 2 of a Report on the workgroup's efforts in exploring these issues.     

Does price deregulation in a competitive hospital market damage quality?

Regulators may be hesitant to permit price competition in healthcare markets because of its potential to damage quality. We assess whether this fear is well founded by examining a reform that permitted Dutch health insurers to freely negotiate prices with hospitals. Unlike previous research on hospital competition that has relied on quality indicators for urgent treatments, we take advantage of a plausible absence of selection bias to identify the effect on the quality of elective procedures that should be more price responsive. Using data on all admissions for hip replacements to Dutch hospitals and a difference-in-differences comparison between more and less concentrated markets, we find no evidence that price deregulation in a competitive environment reduces quality measured by hip replacement readmission rates.