部分国家和地区实施药事服务费的经验综述

我国新医改方案中提出要逐步推进医药分开,积极探索多种有效方式逐步改革以药补医机制,其中改革公立医院补偿机制中很重要的一条就是设立药事服务费。本文集中总结了澳大利亚、加拿大、美国、南非、日本、英国和台湾等国家和地区的经验,界定药事服务费的性质和内涵,介绍国外药事服务费的支付方式、实施情况、监管和配套措施,为我国药事服务费的设立和实施提供一些参考信息。     

Developing service user involvement in the South Korean disability services: lessons from the experience of community care policy and practice in UK

This paper considers the scope for the integration of service user involvement within services for people with disabilities in South Korea at a time of rapid development in social policy and practice. Using the UK experience of introducing community care and a mixed economy of service provision over the last 14 years, this paper considers the barriers to service user involvement inherent in the South Korean context and concludes that in a society where there is a shortage of services and a provider-orientated delivery system where most services are delivered by voluntary organisations, more public services are needed and a 'democratic' rather than a consumerist approach to user involvement is required. Some elements of the UK system could inform the development of a systematic approach to user involvement in South Korea, notably the right to assessment within a care management structure, the setting of quality care standards and inspection processes and a complaints procedure.     

From targeted exemptions to user fee abolition in health care: Experience from rural Zambia

Poor access to health care is one of the greatest impediments to improved health in Africa. In Zambia, user fees are considered to be partly responsible for substantial disparities in access to health care. When the Government introduced user fees in 1993, considerable concern was expressed about the adverse effects on utilisation and access. A national exemption policy was designed to protect the poorest sections of the population. However, this was largely ineffective in reaching the majority of the eligible population.     

The impact of user fee exemption on service utilization and treatment seeking behaviour: the case of malaria in Sudan

This experimental study was undertaken to assess the effect of different levels of exemption, 25%, 50% and 75%, from health centre user fees on health service utilization and treatment seeking behaviour for malaria by a high risk group of pregnant women and children under 5 years. These are groups in need of special medical attention to prevent progression of the disease into complicated or severe malaria. Sinnar State, one of Sudan's highly endemic malaria regions, was selected to be the experimental area. Exemptions were introduced for one year in six health centres. Two centres for each exemption level, and a further two health centres without exemptions were studied. At the beginning and the end of the trial year, households surveys were conducted in the catchment areas of the health centres, and focus group discussions with pregnant women and mothers of children under 5 years were conducted. Routine data were reviewed for malaria cases in the health centres and six studies on malaria cases were done upon exit from the health centres. In-depth interviews with health staff of the health centres were conducted. Exemption from user fees increased health services utilization, improved treatment-seeking behaviour and promoted early diagnosis. The changes during the experimental year were the largest in the centres with the largest exemption. Therefore, policy changes towards exemptions are necessary to facilitate early diagnosis and treatment of malaria.     

The measurement of inequities in health: lessons from the British experience

There has been an acrimonious debate about trends in inequality in health in the U.K. over the last couple of years. Whilst the acrimony is highly specific to the U.K. context, the terms of the debate contain general lessons for others who would venture into the same territory. This paper has focused on problems with using occupational classifications, with using groups of different size, with assessing trends in inequalities in death, with the measurement tool employed, with comparing patterns of ill-health and with the framework of explanation. The U.K. debate provides a good example of the first problem. Much of the debate has had to rely on the classification of occupation at the time of death by the Registrar General's Department. The scheme used was devised in 1911 and has persisted despite the massive changes in occupational structure since then. The groups now contain different occupational titles, and it is not at all clear what is being referred to by the RG scheme. Moreover, the balance of the RG groups has shifted dramatically. Any scheme applied regularly and routinely to mortality statistics over time will have these problems--it is not surprising that it is very difficult to interpret patterns of class death rates. The argument over trends in the U.K. has sometimes focused exclusively on the measurement tool--the standardized mortality ratios. Various alternatives have been proposed, in particular the Gini coefficient which clearly answers a different, possibly rather uninteresting, question. The correct way of comparing 'top' and 'bottom' is to devise a method which produces a group of constant size in the different communities or at different times. The focus on death rather than survivorship is queried as is the usual restriction to comparing rates of early death. Possibilities of comparing patterns of ill-health are examined in the fifth section. Whilst routine health care data or survey morbidity data are invaluable, it seems highly unlikely that they can be compared between communities or over time. The alternative is to develop a series of 'risk' indicators and these are discussed in Section 5.3. The examination of patterns of inequalities in death and ill-health highlights the complexity of discussing aetiology. We consider the balance between long-term and short-term effects and the possible role of (ill)-health on the social mobility process, and problems of directly relating low income to poor health.     

The road to commercialization in Africa: lessons from developing the sickle-cell drug Niprisan

Background

Developing novel drugs from traditional medicinal knowledge can serve as a means to improve public health. Yet countries in sub-Saharan Africa face barriers in translating traditional medicinal knowledge into commercially viable health products. Barriers in moving along the road towards making a new drug available include insufficient manufacturing capacity; knowledge sharing between scientists and medical healers; regulatory hurdles; quality control issues; pricing and distribution; and lack of financing. The case study method was used to illustrate efforts to overcome these barriers during the development in Nigeria of Niprisan – a novel drug for the treatment of sickle cell anemia, a chronic blood disorder with few effective therapies.

Discussion

Building on the knowledge of a traditional medicine practitioner, Nigeria’s National Institute for Pharmaceutical Research and Development (NIPRD) developed the traditional herbal medicine Niprisan. The commercialization of Niprisan reached a number of commercial milestones, including regulatory approval in Nigeria; securing US-based commercial partner XeChem; demonstrating clinical efficacy and safety; being awarded orphan drug status by the US Food and Drug Administration; and striking important relationships with domestic and international groups. Despite these successes, however, XeChem did not achieve mainstream success for Niprisan in Nigeria or in the United States. A number of reasons, including inconsistent funding and manufacturing and management challenges, have been put forth to explain Niprisan’s commercial demise. As of this writing, NIPRD is considering options for another commercial partner to take the drug forward.

Summary

Evidence from the Niprisan experience suggests that establishing benefit-sharing agreements, fostering partnerships with established research institutions, improving standardization and quality control, ensuring financial and managerial due diligence, and recruiting entrepreneurial leaders capable of holding dual scientific and business responsibilities should be incorporated into future drug development initiatives based on traditional medicines. Country-level supporting policies and conditions are also important. With more experience and support, and an improved environment for innovation, developing new drugs from traditional medicines may be an attractive approach to addressing diseases in sub-Saharan Africa and other regions.

     

Health insurance in developing countries: lessons from experience

Many developing countries are currently considering the possibility of introducing compulsory health insurance schemes. One reason is to attract more resources to the health sector. If those who, together with their employers, can pay for their health services and are made to do so by insurance, the limited tax funds can be concentrated on providing services for fewer people and thus improve coverage and raise standards. A second reason is dissatisfaction with existing services in which staff motivation is poor, resources are not used to best advantage and patients are not treated with sufficient courtesy and respect. This article describes the historical experience of the developed countries in introducing and steadily expanding the coverage of health insurance, sets out the consensus which has developed about health insurance (at least in Western European countries) and describes the different forms which health insurance can take. The aim is to bring out the advantages and disadvantages of different approaches from this experience, to set out the options for developing countries and to give warnings about the dangers of some approaches.     

Ministry of Health user fees,equity and decentralization: lessons from Honduras

Decentralization is commonly championed as a means for achieving equity. To date, however, there has been little discussion of the mechanisms underlying this relationship, and several of the few empirical investigations that have addressed the topic have found the converse; that decentralization has exacerbated inequalities. This article examines the performance and equity in financing of the Honduras Ministry of Health's (MOH) decentralized user fee system. The MOH of Honduras established a national user fee policy in 1989. It provided a framework of rules and regulations and decentralized administration of the system to the regional offices. A survey conducted under the auspices of this study provided detailed information about the structures and operations of MOH user fee systems. The survey revealed that the systems vary markedly by region, creating horizontal inequities, and that they have numerous other shortcomings. The average price of a consultation is low, US dollars 0.16, and revenues have consistently equalled just 2% of MOH expenditures. The systems' administrative costs are equal to 67% of their revenues. Eliminating the user fee systems in all but the national and regional hospitals would actually save money and/or enable the MOH to provide more care. Average consultation prices are highest in health posts, intermediate in centres and lowest in the national hospitals, thereby encouraging the inappropriate use of the MOH's pyramidal referral system and fostering MOH inefficiency. Fee levels and exemption practices are horizontally and vertically inequitable. The likelihood of paying for an ambulatory visit is highest at a health post, 89%, and lowest at a hospital, 49%. Individuals from the poorest one-fifth of households are the most likely to have to pay for care. Honduras' experience demonstrates that a decentralized user fee system is not necessarily equitable, and that, more generally, the gains that can be realized from decentralizing user fee systems are not automatic. They must be anticipated, planned for and cultivated by a well-designed and well-implemented initiative that is not a single, one-time event, but rather a dynamic, on-going enterprise.     

The pillars of health management education: lessons from the CEE experience.

AUPHA faculty members have had the opportunity to provide health care executive training and to work in partnership with academic institutions in Central and Eastern Europe and in the New Independent States of the former Soviet Union. This article presents some observations on health management education that demonstrate the similarity in issues faced by programs in the U.S. and in CEE. The health management educational partnership program was designed to provide technical assistance to emerging health management programs in the CEE. The partnership program has been mutually beneficial for several reasons. The role of physicians in leadership and the management educational needs that result provide one example of an issue that health management educational programs must address. The emergence of the roles of other health professions and growing contribution that they will make has its parallel in the American ascendance of the role of interdisciplinary team in clinical decision making. The partnership and executive training experiences have caused U.S. partners to focus consciously on pedagogical methods. The nature of the issues faced by emerging CEE health management programs suggests that mutual support among programs in the region after the partnership program is necessary in order to provide a forum for debate. The focus of the debate should continue to be on the role of management in health reform, content of curriculum, research focus and pedagogical methods appropriate for health care management undergraduate and graduate programs. The result will be a strengthening of the health management academic discipline in the region. The future of the AUPHA should predicated on the same principles, the roots from which it has grown.     

The political environment of HIV: lessons from a comparison of Uganda and South Africa

Considerable interest has arisen in the role of governance or political commitment in determining the success or failure of HIV/AIDS policies in sub-Saharan Africa. During the 1990s, Uganda and South Africa both faced dramatic HIV/AIDS epidemics and also saw transformations to new political systems. However, their responses to the disease differed in many ways. This paper compares and contrasts the ways in which policy environments, particularly government structures, can impede or expedite implementation of effective HIV prevention. Four elements of these environments are discussed--the role of political leadership, the existing bureaucratic system, the health care infrastructure, and the roles assigned to non-state actors. Two common international strategies for HIV prevention, syndromic management of sexually transmitted infections and sexual behaviour change interventions, are examined in relation to these elements in Uganda and South Africa during the mid-to-late 1990s. During this period, Uganda's political system succeeded in promoting behaviour change interventions, while South Africa was more successful in syndromic management efforts. Interactions between the four elements of the policy environment were found to be conducive to such results. These elements are relatively static features of the socio-political environments, so lessons can be drawn for current HIV/AIDS policy, both in these two countries and for a wider audience addressing the epidemic.