改革进程中卫生制度伦理考察与对策思考

分析了我国在改革开放的现实情境中卫生制度的困境与矛盾 ,从伦理人类学和经济伦理学广角提出卫生制度的伦理原则 ,并结合目前我国现行卫生制度状况 ,提出了合理构建卫生服务体系、兼顾卫生资源公平与效率、完善健康保障的结构体系、加强农村及贫困人口的健康保障和注重卫生制度跨部门集成等五个方面的对策建议。     

中国卫生政策发展趋势的伦理学分析

一个国家的卫生系统改革可从社会、政治、经济及伦理学多方面进行分析.本文列举了大量的事实和数据从卫生事业取得的巨大成就说明建国50年来,中国卫生政策的基本伦理学基础是客观的功利主义和平等的自由主义.中国共产党和政府致力于最大限度地提高人民健康水平,保证人人享有公平的基本卫生服务,建立了初级卫生保健及基本医疗保障制度.随着中国社会主义市场经济的发展,中国的卫生政策将逐步建立以市场需求为导向,以病人为中心的卫生服务体系,发展卫生产业.强调满足多层次的医疗需求,提高病人的满意度和就医选择性.卫生费用中个人筹资比例逐渐提高,卫生服务体现公益性和效率优先的原则.卫生政策的伦理学基础已由单纯的客观功利主义转向主观与客观相结合的功利主义.从长远观点看,坚持客观的功利主义和平等的自由主义仍然是制定中国卫生政策的主导思想.     

基于实证分析的我国经济收入与卫生费用关系的地区差异比较

目的:明确中国经济收入与卫生费用的关系,为提高卫生服务公平性提出建议。方法:以居民经济收入、卫生总费用与人均卫生费用为指标,对31省市进行聚类分析。结果:卫生总费用、人均卫生费用与地区经济收入不完全一致,政府卫生政策、卫生资源配置都会对卫生费用产生影响,经济收入并非卫生费用的唯一决定因素。结论:为提高卫生服务的公平性,提出如下建议:优化卫生资源配置,完善政府卫生财政转移支付制度,各类社会医疗保障制度,积极筹措社会资金等。     

卫生经济学视阈中卫生服务公平与效率的关系研究

卫生服务的公平与效率是卫生事业发展的核心问题。卫生服务公平是机会公平、过程公平和质量公平的有机统一;卫生服务效率包括制度效率、经济效率两个方面。基于卫生经济学的视阈,卫生服务中应该坚持"公平优先,兼顾效率"的原则。在宏观上政府要合理的配置卫生资源,积极推进区域卫生计划,提供公平、有效和经济的卫生服务;在微观上加强对医疗机构的经济管理。进而实现公平与效率的和谐统一。     

卫生改革应该提倡一种“公平优先|兼顾效率”的价值观

卫生经济问题无一不具有道德成分，无一能离开伦理政策得以解决。我国卫生改革一开始就缺乏伦理基准，医疗服务过度市场化倾向、政府责任不到位和伦理缺席已将卫生改革引向功利主义的死胡同，使得卫生改革背离了公正目标。我们要正确认识市场的目标、价值和规律。正确理解和发挥政府和市场的调节作用，促进卫生改革的健康发展。在对我国卫生改革的伦理学展望中，我们提倡一种“公平优先，兼顾效率”的价值观。     

我国卫生改革与发展应坚持的价值观和伦理原则

卫生经济问题无一不具有道德成分，无一能离开伦理政策得以解决。我国卫生改革一开始就缺乏伦理基准，医疗服务过度市场化倾向、政府责任不到位和伦理缺席已将卫生改革引向功利主义的死胡同，使得卫生改革背离了公正目标。我们要正确认识市场的目标、价值和规律，正确理解和发挥政府和市场的调节作用，促进卫生改革的健康发展。在对我国卫生改革的伦理学展望中，我们提倡一种“公平优先，兼顾效率”的价值观。     

农村贫困地区政府卫生支出及对卫生机构补偿的变化趋势分析

本文通过对３０个贫困县１９７８～１９９３年间,政府卫生支出的变化趋势和影响因素及其对卫生机构补偿的变化趋势的分析发现：１．在农村贫困地区,政府卫生支出占财政支出的比重远高于全国水平,体现了当地政府对卫生的极大支持,但由于其财力有限,人均政府卫生支出却远低于全国水平;２．政府卫生支出存在分配的不公平性和资源使用效率低下的问题;３．政府卫生投入与卫生机构的业务收入呈负相关,且政府对其投入的变动会引起其业务收入的大幅度变动;４．社会经济及政策因素直接影响政府卫生支出的额度和分配结构。因此,１．上级政府对贫困地区应给予资金和政策上的倾斜;２．有必要调整其分配结构,通过建立农村合作医疗制度,增加政府对农民的直接卫生投入,提高农民卫生服务的需求水平;３．加快公费医疗制度的改革,提高卫生资源的使用效率;４．政府在调整其卫生投入的分配结构时,更应注重完善卫生机构的补偿机制     

我国精神卫生服务投入研究

本文从精神病的病因复杂、病程迁延、容易复发和致残、疾病负担重的医学特征以及精神卫生服务具有明显外部性的经济特征出发，提出了明确划分个人与家庭以及政府对精神卫生服务的责任，进而明确各级政府对精神卫生服务投入的责任，是分担精神卫生服务投入的基础。笔者认为，当务之急是明确中央财政对精神卫生服务投入的责任，建立规范的财政转移支付制度，保障贫困人群获得基本精神卫生服务。     

基本医疗卫生制度对居民基本医疗服务可及性和利用的影响:基于甘肃的个案研究

基本医疗卫生制度建立的目的是消除居民利用基本卫生服务的经济障碍,向全体居民提供适应经济发展阶段和政府及个人承受能力的,安全、有效、方便、价廉的基本医疗服务,促进卫生服务利用公平性的提高。将探索卫生服务可及性和利用的分析方法,并以甘肃省为个案,对基本医疗卫生制度建立前后居民基本医疗服务可及性和利用状况的变化进行测量,评价基本医疗卫生制度对其产生的影响。     

我国政府卫生投入效率研究

以我国18个省市的政府卫生投入作为决策单元,分别从经费投入、人员投入和资本投入3个方面选择投入指标,从医疗卫生机构的服务效率与服务数量两个方面选择产出指标,应用数据包络分析方法研究我国政府卫生投入效率,进而对我国政府卫生投入产出情况进行分析。结果表明,整体上我国政府卫生投入效率较高,但是有的省市实际投入较少,还有一些省市存在一定的资源浪费和资源配置不尽合理等情况,可以通过有针对性地增加政府卫生投入,优化资源配置,提高医疗卫生服务的质量等措施,提高我国的医疗卫生水平。     

从配置优化角度来提高卫生资源利用效率

有效提高卫生资源的利用效率一直是卫生服务研究所追求的目标.政府在医疗、公共卫生和医保三方面对医疗卫生事业进行投入,实行对医疗市场需方和供方同时补贴的政策,既分散了政府的卫生资源,也不利于医疗机构建立自我约束、自我发展的机制.通过盘活存量资产,优化卫生资源配置结构,可提高卫生资源的利用效率,改善医疗卫生行业的整体社会效果.     

Japan's health care system faces a perfect storm

Although Japan has implemented a universal health care system that is universal in terms of free access to health care services, it is managed by fragmented and financially insecure insurance societies that have cumulative deficits even with government subsidies. In terms of insurance premiums, the system is regressive to low-income and unstable workers, and the social benefit scheme only captures 1.6% of this population. The Japanese government is continuously instituting new health care policies to reduce growing health care expenditures. Recent health care reforms may improve economic efficiency, but the changes remain limited to controlling access to health services and pricing measures.     

新医改以来我国卫生筹资的进展、问题与面临的挑战

新医改四年来,我国各级政府大规模增加卫生事业的财政投入,卫生公共筹资体系建设成效显著,然而亦存在一些突出问题,卫生筹资的可持续性面临挑战。当前我国新医改进入“提质增效”的第二季,需要以转变政府管医办医职能为统领,协同配套推进体制机制改革,多渠道增加卫生资源,提高卫生投入绩效,实现卫生筹资的可持续发展。     

The marginal success of regulated competition policy in the Netherlands

In the second half of the 1980s the government in the Netherlands adopted a regulated competition policy as part of a comprehensive programme designed to restructure the health care system. The programme was a product of its social and political context, promoted by a group of political entrepreneurs and created to improve efficiency. Despite the initial political support and a long political debate the government had to acknowledge by 1992 that the restructuring would not take place. But changes fostered limited competition between sickness funds and more extensive competition in the small market for supplementary policies. This, however, has not led to sickness funds becoming powerful purchasers that forced hospitals and doctors to improve their efficiency. Rather, they compete for subscribers, become part of large insurance conglomerates, and market more supplementary options. Culturally, health care institutions have become more entrepreneurial, taken up more business concepts, and made the language of markets, products and consumer sovereignty more common. The impact of these changes on the health care system is still unknown, but they create pressure for more health care services, leaving the government with problems that equal those of the 1980s.     

医保政策对社区卫生服务利用的影响研究

通过分析2005年以来浙江省医疗保险参保人员对社区卫生服务的利用情况，并结合随机偶遇调查，分析参保人员择医行为的主要影响因素，发现：构建社区卫生服务体系的核心是要提高其医疗水平。为此建议：要科学系统地制定社区卫生服务体系构建的规划，进一步建立健全全科医生制度及其培训制度，多方引导参保人员适时调整择医行为，引导参保人员前往社区卫生服务机构就诊。     

Improving the implementation of cost recovery for health: lessons from Zimbabwe

In the current debate over health financing policy in developing countries, governments are increasingly focusing on cost recovery--having patients pay part or all of their health care costs--as a way to mobilize more resources for health, improve equity by selectively charging the wealthy, and increase efficiency by encouraging reinvestment of fee revenues into cost-effective primary care. Zimbabwe offers an important example of a country with a tradition of levying fees in government health facilities, but where enforcement became lax in the 1980s. In 1991, policymakers resolved to resuscitate and strengthen cost recovery, as part of a broader economic reform program. This paper discusses the strengths and weaknesses of Zimbabwe's cost recovery system, its potential for improvement, and the obstacles to change in revising the fee structure and billing and collection procedures. It argues that cost recovery can help to achieve Zimbabwe's health objectives, but only in conjunction with other measures to redirect public spending to essential public health and clinic care and improve the efficiency of government services. The paper finds that during the 1980s, the fee schedule became badly misaligned with actual medical care costs and created distortions in patient referral patterns. Billing and collection were also weak, because of deficiencies in personnel and information systems and lack of incentives for revenue generation. The paper concludes that if key steps were taken to raise the collections-to-billings ratio, recover fees from privately-insured patients, and adjust fees in line with medical cost inflation, recoveries could increase fourfold, from 5% to 20% of government spending for clinical care. At the same time, access to government health services for the poor could be maintained by improving exemption procedures.     

系统提升乡镇卫生院政府投入绩效的策略：理论框架与实证分析

新医改背景下乡镇卫生院综合改革说明政府对基层卫生投入的长效和保障机制正逐步形成,研究提高财政投入绩效具有重要意义。卫生系统是复杂性系统,本研究运用卫生系统绩效框架和机构治理模式理论,结合对广东省15个县市的现场调研,对乡镇卫生院政府投入绩效可能存在的机构效率、县域三级卫生服务体系整体效率和政府卫生投入方式等问题和原因进行了剖析。最后提出系统性提升乡镇卫生院政府卫生投入绩效,应高度重视县域农村医疗卫生服务体系改革的顶层设计;政府各职能部门间的政策制定应相互契合良性互动;要建立基于县域医疗卫生均等化下的符合卫生规律的财政卫生转移支付模式。     

韩国医疗保障体系及其运行方式研究

目的:探讨韩国医疗保障支付体系及其运行方式,为我国医疗保险制度的完善提供借鉴。方法:研究韩国医疗保障制度的基本特点,重点针对其政府采取的基于价值的医疗保险审核与评估支付制度改革经验和制衡式补偿机制。结果:韩国的医疗保障制度特别是其支付制度取得了较好的政策效果。结论:基于价值的医疗保障支付体系推动韩国卫生费用支出降低、卫生政策科学制定。     

Health care expenditures for the elderly and reforms in the health care system in Japan

In recent times, significant reforms have been instituted in Japan's health care system, such as the introduction of hospital categorization and the clarification of hospital roles, together with the establishment of geriatric health care facilities, and the reform of the pharmaceutical distribution and pricing system. These reforms are expected to improve the efficiency and quality of the health care system in Japan and to provide better care for the aging society. The changes will also eventually affect health care costs and patterns of services. This paper describes Japan's health care system, including the recent reforms, and then examines the costs and patterns of health care services for the elderly in the light of the recent changes in the system. While more resource allocation is necessary for training of workers for nursing, rehabilitation and care-giving, drugs should be more cost-effective and fit for use at home and in non-medically oriented institutions. Health care providers, health care industries and the government need further to properly respond to the changes in demography, patterns of diseases and disabilities and patients' wishes for better quality of life.     

Health economics and resource management: a model for hospital efficiency

As health care spending continues to climb, government and industry, as the two major purchasers of health care services, are intensifying their scrutiny over health care delivery in an attempt to reduce their health care burden. The first round of utilization controls and reimbursement restrictions focused on necessity of admission and efficiency of care, causing a profound effect on hospital-based services. Declining occupancy rates, reduced inpatient reimbursements, and mounting contractual losses have pushed many hospitals to the point of financial disaster. The second round of controls has expanded into the outpatient sector and will begin to focus on both appropriateness of treatment and outcome of care, affecting both hospital and physician-related services. In an environment of increasing external pressures for appropriateness, justification and outcome of medical services, and potential financial risk imposed by reimbursement cutoffs or penalties for unnecessary care, hospitals and physicians are under increasing pressure to improve their efficiency as health care providers. The resource management model is presented as an example of how hospitals and physicians can monitor health care services and improve their performance in the delivery of more cost-efficient, high-quality medical care. The importance of hospital-physician education, communication, and interaction is stressed as a means of attaining internal control over a system plagued by resource-limited external constraints.