政府公共支出受益归属分析研究进展

继2005年世界卫生组织提出全民健康覆盖后,全民健康覆盖成了包括我国在内的大部分国家卫生改革的一个重要目标。受益归属分析作为一种评估卫生系统筹资和服务利用公平性的工具被广泛使用。文章在介绍传统BIA法的基础上,重点阐述了国外静态受益归属分析和动态受益归属分析的研究进展,并对BIA在我国的研究前景和重点进行了展望。     

Mortality reductions from marginal increases in public spending on health

There is limited empirical evidence of the nature of any relationship between health spending and health outcomes in Australia. We address this by estimating the elasticity of health outcomes with respect to public healthcare spending using an instrumental variable (IV) approach to account for endogeneity of healthcare spending to health outcomes. Results suggest that, based on the conditional mean, a 1% increase in public health spending was associated with a 2.2% (p < 0.05) reduction in the number of standardised Years of Life Lost (YLL). Sensitivity analyses and robustness checks supported this conclusion. Further exploration using IV quantile regression indicated that marginal returns on public health spending were significantly greater for areas with poorer health outcomes compared to areas with better health outcomes. On average, marginal increases in public health spending reduce YLL, but areas with poorer health outcomes have the greatest potential to benefit from the same marginal increase in public health spending compared to areas with better health outcomes. Understanding the relationship between health spending and outcomes and how this differs according to baseline health outcomes can help meet dual policy objectives to improve the productivity of the healthcare system and reduce inequity.     

Association between non-profit hospital community benefit spending and health outcomes

Objective

To determine if greater non-profit hospital spending for community benefits is associated with better health outcomes in the county where they are located.

Data Sources and Study Setting

Community benefit data from IRS Form 990/Schedule H was linked to health outcome data from Area Health Resource Files, Map the Meal Gap, and Medicare claims from the Center for Medicare and Medicaid Services at the county level. Counties with at least one non-profit hospital in the United States from 2015 to 2019 (N = 5469 across the 5 years) were included.

Study Design

We ran multiple regressions on community benefit expenditures linked with the number of health professionals, food insecurity, and adherence to diabetes and hypertension medication for each county.

Data Collection

The three outcomes were chosen based on prior studies of community benefit and a recent survey sent to 12 health care executives across four regions of the U.S. Data on community benefit expenditures and health outcomes were aggregated at the county level.

Principal Findings

Average hospital community benefit spending in 2019 was $63.6 million per county ($255 per capita). Multivariable regression results did not demonstrate significant associations of total community benefit spending with food insecurity or medication adherence for diabetes. Statistically significant associations with the number of health professionals per 1000 (coefficient, 12.10; SE, 0.32; p < 0.001) and medication adherence for hypertension (marginal effect, 0.27; SE, 0.09; p = 0.003) were identified, but both would require very large increases in community benefit spending to meaningfully improve outcomes.

Conclusions

Despite varying levels of non-profit hospital community benefit investment across counties, higher community benefit expenditures are not associated with an improvement in the selected health outcomes at the county level. Hospitals can use this information to reassess community benefit strategies, while federal, state, and local governments can use these findings to redefine the measures of community benefit they use to monitor and grant tax exemption.     

Economic impact of public sector spending on health care

Public sector spending on health care clearly has a positive economic impact on local communities. Not only does such spending provide residents with better health care, but it is widely recognized as an investment that returns continual dividends in the form of better jobs, higher incomes, and additional state and local tax revenues. The results of a static input/output model shows that public sector spending on health care of approximately $46 billion (in 2009 dollars) in the state of Texas yields over 588,000 jobs, $74.2 billion in total output, $26.3 billion in personal income, $22 billion in employee compensation, and $1.8 billion in state and local taxes; it clearly has a considerable positive economic impact on local economies and their quest for economic development.     

Getting what you pay for: public health spending and the performance of essential public health services.

Governmental spending in public health varies widely across communities, raising questions about how these differences may affect the availability of essential services and infrastructure. This study used data from local public health systems that participated in the National Public Health Performance Standards Program pilot tests between 1999 and 2001 to examine the association between public health spending and the performance of essential public health services. Results indicated that performance varies significantly with both local and federal spending levels, even after controlling for other system and community characteristics. Some public health services appear more sensitive to these expenditures than others, and all services appear more sensitive to local spending than to state or federal spending. These findings can assist public health decision makers in identifying public health financing priorities during periods of change in the resources available to support local public health infrastructure.     

Government spending on health care: a cross-national study of public attitudes

The economic constraints of the last decade have led western industrialized nations to consider, if not actually adopt, more stringent controls over costly social policies such as health care. Using recent, nationally representative data from the United States, Great Britain, West Germany, Italy and Australia, this paper provides an international comparison of attitudes towards government spending on health care. Attitudes are found to differ by country, with Great Britain being most supportive of increased spending and West Germany and the United States most opposed. Multiple regression techniques are used to determine significant socio-demographic and political ideological factors in relation to predicting attitudes towards government spending. In many countries, those who often bear the heavier tax burden, for example, the middle classes and those with higher status jobs, were consistently more likely to oppose an increase in government spending on health; compared with them, women were found to be more supportive of such action. Measures of political ideology were found to be quite consistent and strong predictors of attitudes--political conservatism and more negative attitudes towards government generally were inversely related to support for government increases in health spending. The policy implications of these findings are discussed in the conclusion.     

Unemployment and self-assessed health: evidence from panel data

We examine the relationship between unemployment and self-assessed health using the European Community Household Panel for Finland over the period 1996-2001. Our results show that the event of becoming unemployed does not matter as such for self-assessed health. The health status of those that end up being unemployed is lower than that of the continually employed. Therefore, persons who have poor health are being selected for the pool of the unemployed. This explains why, in a cross-section, unemployment is associated with poor self-assessed health. All in all, the cross-sectional negative relationship between unemployment and self-assessed health is not found longitudinally.     

The impact of public employment on health and health inequalities: evidence from China

Because the public and private sectors often operate with different goals, individuals employed by the two sectors may receive different levels of welfare. This can potentially lead to different health status. As such, employment sector offers an important perspective for understanding labor market outcomes. Using micro-level data from a recent Chinese household survey, this study empirically evaluated the impact of employment sector on health and within-sector health inequalities. It found that public sector employment generated better health outcomes than private sector employment, controlling for individual characteristics. The provision of more job security explained an important part of the association between public sector employment and better health. The study also found less health inequality by social class within the public sector. These findings suggest that policymakers should think critically about the "conventional wisdom" that private ownership is almost always superior, and should adjust their labor market policies accordingly.     

Improving Aboriginal health data capture: evidence from a health registry evaluation

The lack of high-quality health information for accurately estimating burdens of disease in some Aboriginal populations is a challenge for developing effective and relevant public health programmes and for health research. We evaluated data from a health registry system that captured patient consultations, provided by Labrador Grenfell Health (Labrador, Canada). The goal was to evaluate the registry's utility and attributes using modified CDC guidelines for evaluating surveillance systems. Infectious gastrointestinal illness data were used as a reference syndrome to determine various aspects of data collection and quality. Key-informant interviews were conducted to provide information about system utility. The study uncovered limitations in data quality and accessibility, resulting in region-specific recommendations including conversion to an electronic system. More generally, this study emphasized how a systematic and standardized evaluation of health registry systems can help address challenges to obtaining quality health data in often remote areas where many Aboriginal communities are found.     

The sustainability of public health expenditures: evidence from the Canadian federation

The fiscal sustainability of government health expenditures is defined as the gap between growth rates of spending and measures of the resource base. The results show that over the period 1965–2008, real per capita Canadian provincial government health spending has grown at rates that exceed growth in basic measures of the resource base such as per capita gross domestic product (GDP), per capita federal transfers and per capita provincial government revenues. Forecasts of future spending to 2035 using determinant regression and growth rate extrapolation techniques show that Canadian provincial government health spending is projected to continue rising in the future and its share of provincial GDP will rise. While the amount spent on health is ultimately a public policy choice, provincial government health spending also cannot continue growing faster than the resource base indefinitely.     

Institutional public private partnerships for core health services: evidence from Italy

Background  

Public-private partnerships (PPPs) are potential instruments to enable private collaboration in the health sector. Despite theoretical debate, empirical analyses have thus far tended to focus on the contractual or project dimension, overlooking institutional PPPs, i.e., formal legal entities run by proper corporate-governance mechanisms and jointly owned by public and private parties for the provision of public-health goods. This work aims to fill this gap by carrying out a comparative analysis of the reasons for the adoption of institutional PPPs and the governance and managerial features necessary to establish them as appropriate arrangements for public-health services provisions.     

Protecting households from catastrophic health spending

Many countries rely heavily on patients' out-of-pocket payments to providers to finance their health care systems. This prevents some people from seeking care and results in financial catastrophe and impoverishment for others who do obtain care. Surveys in eighty-nine countries covering 89 percent of the world's population suggest that 150 million people globally suffer financial catastrophe annually because they pay for health services. Prepayment mechanisms protect people from financial catastrophe, but there is no strong evidence that social health insurance systems offer better or worse protection than tax-based systems do.     

Multi-sectoral health promotion and public health: the role of evidence

BACKGROUND: Evidence-informed health promotion and public health is an emerging and ever-changing theme in research and practice. A collaborative approach to gathering and applying evidence is crucial to implementing effective multi-sectoral health promotion and public health interventions for improved population outcomes. This paper presents an argument for the development of multi-sector evidence and discusses both facilitators and challenges to this process. METHODS: Sector-specific contacts familiar with decision-making processes were selected from referrals gained through academic, government and non-government networks and interviewed (in-person or via telephone) as part of a small scale study to scope the use of evidence within non-health sectors where decisions are likely to impact on public health. RESULTS: The views gathered are preliminary, and this analysis would benefit from more extensive consultation. Nonetheless, information gathered from the interviews and literature search provide valuable insights into evidence-related decision-making paradigms which demonstrate similarities with, and differences from, those found in the health sector. CONCLUSIONS: Decisions in health promotion and public may benefit from consideration of the ways in which disciplines and sectors can work together to inform policy and practice.     

Healthcare spending inequality: Evidence from Hungarian administrative data

Using administrative data on a random 50% of the Hungarian population, including individual-level information on incomes, healthcare spending, and mortality for the 2003–2011 period, we develop new evidence on the distribution of healthcare spending and mortality in Hungary by income and geography. By linking detailed administrative data on employment, income, and geographic location with measures of healthcare spending and mortality we are able to provide a more complete picture than the existing literature which has relied on survey data. We compute mean spending and 5-year and 8-year mortality measures by geography and income quantiles, and also present gender and age adjusted results.We document four patterns: (i) substantial geographic heterogeneity in healthcare spending; (ii) positive association between labor income and public healthcare spending; (iii) geographic variation in the strength of the association between labor income and healthcare spending; and (iv) negative association between labor income and mortality. In further exploratory analysis, we find no statistically significant correlation between simple county-level supply measures and healthcare spending. We argue that taken together, these patterns suggest that individuals with higher labor income are in better health but consume more healthcare because they have better access to services.Our work suggests new directions for research on the relationship between health inequalities and healthcare spending inequalities and the role of subtler barriers to healthcare access.     

Debt relief and public health spending in heavily indebted poor countries

The Heavily Indebted Poor Countries (HIPC) Initiative, which was launched in 1996, is the first comprehensive effort by the international community to reduce the external debt of the world's poorest countries. The Initiative will generate substantial savings relative to current and past public spending on health and education in these countries. Although there is ample scope for raising public health spending in heavily indebted poor countries, it may not be advisable to spend all the savings resulting from HIPC resources for this purpose. Any comprehensive strategy for tackling poverty should also focus on improving the efficiency of public health outlays and on reallocating funds to programmes that are most beneficial to the poor. In order to ensure that debt relief increases poverty-reducing spending and benefits the poor, all such spending, not just that financed by HIPC resources, should be tracked. This requires that countries improve all aspects of their public expenditure management. In the short run, heavily indebted poor countries can take some pragmatic tracking measures based on existing public expenditure management systems, but in the longer run they should adopt a more comprehensive approach so as to strengthen their budget formulation, execution, and reporting systems.