我国基层卫生机构服务功能分析

基层卫生机构功能决定着基本卫生服务的供给。本文利用国家第四次卫生服务总调查以及专题调查资料,对城乡基层卫生机构服务开展情况进行了分析。根据经济社会发展水平、基层卫生机构服务能力和城乡居民需要解决的主要健康问题,本研究将基本卫生服务项目按照优先程度分为三个等级。约三分之一的城乡基层卫生机构尚不能提供最应优先开展的基本卫生服务;农村基层卫生机构服务能力与城市基层卫生机构相比更为薄弱,特别是村级卫生机构基本卫生服务能力需要加强;乡镇卫生院和社区卫生服务中心开展最优先项目的比例均不足70%;村卫生室和社区服务站开展最优先项目比例分别为62%和77%。影响基层卫生机构功能的主要因素为人员数量不足、人员能力不够、缺乏运转资金等。需要以基层卫生机构功能建设为核心,创新我国基本医疗卫生保健体系。     

Using population segmentation to provide better health care for all: the "Bridges to Health" model

The model discussed in this article divides the population into eight groups: people in good health, in maternal/infant situations, with an acute illness, with stable chronic conditions, with a serious but stable disability, with failing health near death, with advanced organ system failure, and with long-term frailty. Each group has its own definitions of optimal health and its own priorities among services. Interpreting these population-focused priorities in the context of the Institute of Medicine's six goals for quality yields a framework that could shape planning for resources, care arrangements, and service delivery, thus ensuring that each person's health needs can be met effectively and efficiently. Since this framework would guide each population segment across the institute's "Quality Chasm," it is called the "Bridges to Health" model.     

Challenges facing primary health care in federated government systems: Implementation of Primary Health Networks in Australian states and territories

In many federated countries, there is divided health system responsibility that can affect primary health care (PHC) policy and implementation, and complicate collaboration between PHC actors. We examined an Australian policy initiative, Primary Health Networks (PHNs), which are regional PHC organisations, to examine how they collaborated with state and territory PHC actors, and what factors enhanced or constrained collaboration. For PHNs we surveyed 66 staff, interviewed 82 staff, examined board membership, and analysed documents from all 31 PHNs. We also interviewed 11 state and 5 federal health bureaucrats. We mapped the PHC system in each state, and conducted team thematic analysis of the qualitative data collected. We found variation in how well PHNs collaborated with state and territory actors, ranging from poor relationships through to strong cooperation and co-commissioning. This was affected by factors to do with the state health department, geography, PHN funding and regulations, ambiguities in the federal/state divided responsibilities for PHC, and the extent of use of collaboration mechanisms and strategies. Resourcing and supporting such collaboration mechanisms, and increasing regional funding flexibility of funding would increase the potential for regional organisations to successfully navigate ambiguities in responsibility and foster a more integrated, cohesive PHC system.     

发展城乡基层卫生事业是实施基本卫生保健制度的基础

当前城乡基层卫生事业存在卫生资源不足且城乡差距明显、基本医疗得不到保障舍近求远使看病难导致看病贵、公共卫生服务缺失使危害居民健康因素的隐患增大等主要问题，提出发展城乡基层卫生事业是实施基本卫生保健制度基础的观点，提出把巩固完善城乡基层卫生体系和提高卫生服务能力作为基础工程、把增加卫生投入和实行公共卫生服务政府埋单作为保障工程、把改造不良生活卫生环境和倡导健康生活方式作为配套工程等三个发展城乡基层卫生事业和实施国家基本卫生保健制度的政策建议。     

The excess health care costs of KardioPro,an integrated care program for coronary heart disease prevention

Coronary heart disease (CHD) is a major cause of death and important driver of health care costs. Recent German health care reforms have promoted integrated care contracts allowing statutory health insurance providers more room to organize health care provision. One provider offers KardioPro, an integrated primary care-based CHD prevention program. As insurance providers should be aware of the financial consequences when developing optional programs, this study aims to analyze the costs associated with KardioPro participation. 13,264 KardioPro participants were compared with a propensity score-matched control group. Post-enrollment health care costs were calculated based on routine data over a follow-up period of up to 4 years. For those people who incurred costs, KardioPro participation was significantly associated with increased physician costs (by 33%), reduced hospital costs (by 19%), and reduced pharmaceutical costs (by 16%). Overall costs were increased by 4%, but this was not significant. Total excess costs per observation year were €131 per person (95% confidence interval: [€−36.5; €296]). Overall, KardioPro likely affected treatment as the program increased costs of physician services and reduced costs of hospital services. Further effects of substituting potential inpatient care with increased outpatient care might become fully apparent only over a longer time horizon.     

Management development for primary health care: a framework for analysis

Strengthening management has been widely promoted as a critical component of any strategy concerned with improving the implementation of primary health care (PHC). Management development programmes are, however, subject to conflicting demands and differing expectations. The situation is confounded by the wide diversity of strategies subsumed under the heading of management development, and the confusing nature of much of the terminology currently in use. This article presents a simple conceptual framework that can guide analysis and help programme planners review the options, opportunities and limitations of management development programmes. The framework presented examines management development from three different perspectives: the approach adopted; the outcomes expected; and the process of expansion, extension and adaptation. Our analysis of management development strategies allows us to reach some conclusions in areas where there is a degree of consensus. In countries where there is a mismatch between the strategies of PHC and the organizational structures through which they are to be implemented, management development has a role to play in effecting change. Its potential to do so is limited by powerful social, political, economic and organizational forces. Therefore, the capacity to critically analyse the context in which change is planned, emerges as a key element in programme design. We argue that there is no one best approach to management development, and the design of strategies will be contingent on a variety of factors. We do, however, reaffirm the view that where organizational structures and conditions do not support the implementation of PHC strategies, intervention through training alone is almost certain to be inadequate. To be effective, a more comprehensive programme will be required. Finally, the article points to a number of unresolved issues in areas where there is either controversy, lack of clarity or limited experience.     

Health insurance and imperfect competition in the health care market

We show that when health care providers have market power and engage in Cournot competition, a competitive upstream health insurance market results in over-insurance and over-priced health care. Even though consumers and firms anticipate the price interactions between these two markets - the price set in one market affects the demand expressed in the other - Pareto improvements are possible. The results suggest a beneficial role for Government intervention, either in the insurance or the health care market.     

中国农村基本卫生保健工作发展与思考

目的：了解我国农村地区基本卫生保健工作的现状,以及在新世纪第一个十年中取得的成绩和存在的问题,为进一步推进农村基本卫生保健工作提出有针对性的政策建议。方法：按照分层抽样的方法,在全国选择400个县级行政单位,收集当地农村基本卫生保健工作的相关数据。结果与发现：（1）农村基本卫生保健工作得到政府重视,但财政保障仍不足;（2）乡村两级医疗卫生服务体系建设仍需不断完善;（3）基本公共卫生服务在医改政策推动下进展明显,后续要加大力度推进;（4）新型农村合作医疗制度不断完善;（5）基本药物制度实施使基层医疗卫生机构面临发展困境。     

Penalizing patients and rewarding providers: user charges and health care utilization in Vietnam

The introduction of a comprehensive system of user charges in 1995 provided public health facilities in Vietnam, especially hospitals, with a growing source of revenue. By 1998 revenues from user charges accounted for 30% of public hospital revenues. Increasingly, provider incomes have relied on fee revenues and provision-based bonuses, the effect of which is that a poorly regulated fee-for-service system has replaced a salary system based upon a centrally determined global budget. This paper examines the potential influence of providers' on the use of publicly provided health services. Using facility-based data over the period 1996-98, the relative contribution of treatment intensity is compared and contrasted under the two sources of hospital revenues from patients, namely a user charge system and a third party payment system based on fee-for-services. The primary focus of the comparison is on the treatment intensity for all hospital contacts, hospital admissions and the length of hospital stays, decisions normally taken by the providers and over which patients have little or no influence. The results indicate that growth in patient revenues was associated with large increases in intensity. The growth in intensity was more pronounced in the case of inpatient contacts. Moreover, both the admission rate and the length of hospital stay were far higher for better off individuals than for the poor, and greater for the insured than the uninsured. The increase in the intensity of hospital care for both health insurance enrollees and the uninsured can be seen as, among other things, an attempt on the part of providers to increase revenue from health insurance premiums and user charges in the face of a shrinking share of public resources allocated to hospitals, and low wages and salaries.     

The effects of price competition and reduced subsidies for uncompensated care on hospital mortality

OBJECTIVE: To determine whether hospital mortality rates changed in New Jersey after implementation of a law that changed hospital payment from a regulated system based on hospital cost to price competition with reduced subsidies for uncompensated care and whether changes in mortality rates were affected by hospital market conditions. DATA SOURCES/STUDY SETTING: State discharge data for New Jersey and New York from 1990 to 1996. Study Design. We used an interrupted time series design to compare risk-adjusted in-hospital mortality rates between states over time. We compared the effect sizes in markets with different levels of health maintenance organization penetration and hospital market concentration and tested the sensitivity of our results to different approaches to defining hospital markets. DATA COLLECTION/EXTRACTION METHODS: The study sample included all patients under age 65 admitted to New Jersey or New York hospitals with stroke, hip fracture, pneumonia, pulmonary embolism, congestive heart failure, hip fracture, or acute myocardial infarction (AMI). PRINCIPAL FINDINGS: Mortality among patients in New Jersey improved less than in New York by 0.4 percentage points among the insured (p=.07) and 0.5 percentage points among the uninsured (p=.37). There was a relative increase in mortality for patients with AMI, congestive heart failure, and stroke, especially for uninsured patients with these conditions, but not for patients with the other four conditions we studied. Less competitive hospital markets were significantly associated with a relative decrease in mortality among insured patients. CONCLUSIONS: Market-based reforms may adversely affect mortality for some conditions but it appears the effects are not universal. Insured patients in less competitive markets fared better in the transition to price competition.     

The Indigenous primary health care and policy research network: Guiding innovation within primary health care with Indigenous peoples in Alberta

In 2015, the Truth and Reconciliation Commission of Canada released its Final Report with 94 Calls to Action, several of which called upon the health care sector to reform based on the principles of reconciliation. In the province of Alberta, Canada, numerous initiatives have arisen to address the health legacy Calls to Action, yet there is no formal mechanism to connect them all. As such, these initiatives have resulted in limited improvements overall. Recognizing the need for clear leadership, responsibility, and dedicated funding, stakeholders from across Alberta were convened in the Spring of 2019 for two full-day roundtable meetings to provide direction for a proposed Canadian Institutes of Health Research Network Environment for Indigenous Health Research that focused on primary health care and policy research. The findings from these roundtable meetings were synthesized and integrated into the foundational principles of the Indigenous Primary Health Care and Policy Research (IPHCPR) Network. The IPHCPR Network has envisioned a renewed and transformed primary health care system to achieve Indigenous health equity, aligned with principles and health legacy Calls to Action advocated by the Truth and Reconciliation Commission of Canada.     

北京市乡村两级基本医疗卫生服务包设计研究

阐述了北京市乡村两级基本医疗卫生服务项目的 筛选原则与依据,提出了北京市农村基本卫生服务包的筛选标准,获得了北京市乡村两级基本医疗卫生服务包的筛选结果,分析了基本医疗卫生服务包的合理性、适应性及可操作性,并探讨了开展基本医疗卫生服务的保障条件,以供其他地区借鉴.     

Essential national health research in developing countries: Health-care financing and the quality of care

New research integrating expertise in financing and quality assurance is critical at times when resource constraints threaten to undermine the sustainability of effective healthcare services. Cost-effectiveness is related to the quality of the health-care intervention. In the economics literature, health-care demand studies generally indicate that quality is an important determinant of utilization patterns, but do not clearly identify those components of quality most important to the patient. On the supply side, cost analyses have not closely examined cost-quality tradeoffs, nor the net costs of quality. Policy makers must determine the affordability of cost-recovery mechanisms, which include both increases in price and quality. Further research should identify those aspects of quality which will maximize effectiveness at the least cost, thus helping to promote the financial sustainability of the health service.     

Review of 128 quality of care mechanisms: A framework and mapping for health system stewards

Health system stewards have the critical task to identify quality of care deficiencies and resolve underlying system limitations. Despite a growing evidence-base on the effectiveness of certain mechanisms for improving quality of care, frameworks to facilitate the oversight function of stewards and the use of mechanisms to improve outcomes remain underdeveloped. This review set out to catalogue a wide range of quality of care mechanisms and evidence on their effectiveness, and to map these in a framework along two dimensions: (i) governance subfunctions; and (ii) targets of quality of care mechanisms. To identify quality of care mechanisms, a series of searches were run in Health Systems Evidence and PubMed. Additional grey literature was reviewed. A total of 128 quality of care mechanisms were identified. For each mechanism, searches were carried out for systematic reviews on their effectiveness. These findings were mapped in the framework defined. The mapping illustrates the range and evidence for mechanisms varies and is more developed for some target areas such as the health workforce. Across the governance sub-functions, more mechanisms and with evidence of effectiveness are found for setting priorities and standards and organizing and monitoring for action. This framework can support system stewards to map the quality of care mechanisms used in their systems and to uncover opportunities for optimization backed by systems thinking.     

Regional variation in health care utilization and mortality

Geographic variation in health care utilization has raised concerns of possible inefficiencies in health care supply, as differences are often not reflected in health outcomes. Using comprehensive Norwegian microdata, we exploit cross-region migration to analyze regional variation in health care utilization. Our results indicate that place factors account for half of the difference in utilization between high and low utilization regions, while the rest reflects patient demand. We further document heterogeneous impacts of place across socioeconomic groups. Place factors account for 75% of the regional utilization difference for high school dropouts, and 40% for high school graduates; for patients with a college degree, the impact of place is negligible. We find no statistically significant association between the estimated place effects and overall mortality. However, we document a negative association between place effects and utilization-intensive causes of death such as cancer, suggesting high-supply regions may achieve modestly improved health outcomes.