Comparative quality of private and public health services in rural Vietnam

BACKGROUND: Private health care services were officially recognized in Vietnam in 1989, and for the last 15 years have competed with the public health system in providing primary curative care and pharmaceutical sales to rural populations. However, the quality of these private and public health care services has not been evaluated and compared. METHODS: A community-based survey was conducted in 30 of the 160 communes in Hung Yen, which were selected by probability proportional to population size (PPS) sampling. All commune health centres (CHCs) and private health care providers in the selected communes were surveyed on human resources, services provided, availability of medical equipment and pharmaceuticals, knowledge and clinical performance for acute and chronic problems. Patient satisfaction and cost of care associated with recent illness were measured using a random household survey covering 30 households from each of the selected communes. RESULTS: There were 11.5 private providers per 10,000 population, compared with 6.7 public providers per 10,000. A quarter of private providers were employees of the public health sector. Less than 20% of the private providers had registered their practice with the government system. Eleven per cent (26/234) had no professional qualifications. Fifty-eight per cent (135/234) provided treatment as well as selling medications. Public sector infrastructure was superior to that of the private providers. The quality of services provided by public providers was poor but significantly better than that of private providers. Patient satisfaction and costs of care were similar between the two groups. CONCLUSIONS: Private providers are successfully competing with the public health centre system in rural areas but not because they provide cheaper or better services. The quality of private health care services is not controlled and is significantly poorer than public services. Current practice in both systems falls below the national standard, especially for the management of chronic health problems. The low quality of health care services at a community level may help explain the previously observed phenomena of high levels of self-medicating, low utilization of commune health centres and over-utilization of tertiary health care facilities.     

The impact of public voluntary health insurance on private health expenditures in Vietnam

As a financing mechanism with the potential to raise additional funds for health services, whilst improving access to services amongst the poor, non-profit health insurance has become increasingly attractive to health policy-makers. Using data from a household survey in Vietnam, out of pocket health expenditure are compared between members and eligible non-members of the government-implemented voluntary health insurance scheme. Expenditures are analysed for individuals who sought care during their most recent illness. Using an endogenous dummy variable model to control for bias resulting from self-selection into the scheme, we find that health insurance reduces average out-of-pocket expenditures by approximately 200%. Whilst income inelastic, health expenditures are found to be significantly influenced by an individuals level of income, irrespective of insurance status. Despite this, insurance reduces expenditures significantly more for the poor than for the rich.     

公共卫生服务提供的公私合作模式综述

通过系统整理和分析国内外关于公共卫生服务提供的公私合作模式的研究文献,阐述了公私合作模式的内涵、分类和国内外公共卫生服务公私合作的主要方式和实践应用,并阐明了公共卫生服务领域公私合作对减轻政府财政压力、推动卫生体制创新、促进政府职能转换、提高公共卫生服务效率、提高私立卫生机构综合竞争力及贫困人群服务公平性都有积极作用;指出了公私合作过程中存在合作双方缺乏信任、沟通不足、政府管理滞后、职能不强等影响服务效果的问题;建议建立公私部门信息共享机制、设计合理的风险分担机制、改进政府对公私合作的管理手段、强化政府主导作用等措施;启示我国在基本公共卫生服务公私合作供给过程中要强化政府职责、成立第三方组织对公私合作进行协调、沟通、监督和考核以及建立有效的公私合作机制。     

Socioeconomic patterns in the use of public and private health services and equity in health care

Background  

Several studies in wealthy countries suggest that utilization of GP and hospital services, after adjusting for health care need, is equitable or pro-poor, whereas specialist care tends to favour the better off. Horizontal equity in these studies has not been evaluated appropriately, since the use of healthcare services is analysed without distinguishing between public and private services. The purpose of this study is to estimate the relation between socioeconomic position and health services use to determine whether the findings are compatible with the attainment of horizontal equity: equal use of public healthcare services for equal need.     

Measuring the effects of reducing subsidies for private insurance on public expenditure for health care

This paper investigates the effects of reducing subsidies for private health insurance on public sector expenditure for hospital care. An econometric framework using simultaneous equation models is developed to analyse the interrelated decisions on the intensity and type of health care use and private insurance. The framework is applied to the context of the mixed public–private system in Australia. The simulation projections show that reducing premium subsidies is expected to generate net cost savings. This arises because the cost savings achieved from reducing subsidies are larger than the potential increase in public expenditure on hospital care.     

健康素养对妇女儿童基本公共卫生服务利用的 影响研究

摘要:目的　了解城市妇女儿童的基本公共卫生服务利用情况和儿童母亲的健康素养状况,探索儿童母亲的健康素养对其基本公共卫生服务利用的影响。方法　采用多阶段整群随机抽样方法,对北京、宁波和厦门三城市的1 048名0～6岁儿童母亲进行问卷调查。使用卡方检验和多因素Logistic回归分析健康素养与基本公共卫生服务利用之间的关系。结果　所调查的母亲健康素养水平为低、中、高的比例分别为38.27%、29.00%和32.73%。34.26%的母亲建立了健康档案,36.27%的能够利用健康教育服务,孕12周参加免费体检者为47.10%,进行产前筛查者占85.24%;能按时接受产前检查者占92.94%,分别有81.01%和97.52%的儿童规范参加了健康管理和疫苗接种;Logistic回归结果显示,健康素养与建立健康档案（OR＝0.446,95%CI:0.329～0.604）、接受健康教育（OR＝1.451,95%CI:1.100～1.914）、产前检查（OR＝2.094,95%CI:1.089～4.026）、儿童健康管理（OR＝1.891,95%CI:1.246～2.872）存在关联。结论　健康素养水平能够影响到妇女儿童基本公共卫生服务的利用,建议针对儿童母亲开展更多旨在提高其健康素养水平的活动,进而促进妇女和儿童对基本公共卫生服务的利用。     

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.     

母亲健康素养对儿童利用基本公共卫生服务项目的影响研究

目的 了解本社区0～6岁儿童对基本公共卫生服务的利用情况,分析儿童母亲健康素养得分水平对0～6岁儿童利用基本公共卫生服务的影响,为提高社区居民对基本公共卫生服务的利用提供理论依据.方法 采用方便抽样方法,对北京市某社区的429名0～6岁儿童及其母亲进行问卷调查,使用t检验、卡方检验和方差分析儿童母亲年龄、文化程度、收入水平、健康素养水平等因素对其利用基本公共卫生服务的影响程度.结果 被调查的儿童中,年龄≤1岁为236人,1＜年龄≤2岁为44人,2＜年龄≤6岁为149人,各年龄组男女比例接近,组间差异无统计学意义.年龄＞ 30岁组的母亲其健康素养得分最高;儿童母亲的文化程度越高,其健康素养得分也越高;随着家庭人均月收入的提高,儿童母亲的健康素养得分也逐步提高.儿童母亲健康素养平均得分为(6.4±1.3)分;能接受健康管理的为81.8％、按规范参加计划免疫的为97.0％,遵医嘱服药为95.1％;母亲健康素养得分高的儿童接受健康管理的比例为86.3％,高于母亲健康素养得分低的儿童(76.1％),差异有统计学意义.结论 儿童母亲健康素养水平是儿童利用基本公共卫生服务的重要影响因素.     

健康素养与老年居民基本公共卫生服务利用的关系研究

目的了解城市老年居民的健康素养状况和基本公共卫生服务利用情况,探索健康素养与老年居民利用基本公共卫生服务的关系。方法采用两阶段整群系统抽样方法,对北京、宁波和厦门3城市的1947名65岁及以上老年人进行问卷调查。使用χ2检验和多因素Logistic回归分析健康素养与基本公共卫生服务利用的关系。结果 46.94%的调查对象建立了健康档案,41.35%能够利用健康教育服务。多变量Logistic回归结果显示,高健康素养与低健康素养者相比更倾向于建立健康档案（OR=1.573,95%CI：1.209~2.047）、接受健康教育（OR=1.308,95%CI：1.029~1.662）、接种流感疫苗（OR=1.691,95%CI：1.349~2.12）、参加免费体检（OR=1.544,95%CI：1.197~1.991）和生活方式指导（OR=2.401,95%CI：1.884~3.061）。结论健康素养水平可能影响到老年居民基本公共卫生服务的利用,建议开展更多旨在提高居民健康素养水平的活动,并减少低健康素养者利用基本公共卫生服务过程中的困难,进而增加居民对基本公共卫生服务的利用。     

中国慢性病及相关危险因素流行趋势、面临问题及对策

  目的  分析糖尿病患者的灾难性卫生支出及其与收入相关的不平等性。  方法  利用陕西省国家卫生调查2013年数据,以糖尿病患者家庭为研究对象,利用WHO的方法界定的灾难性卫生支出,并进一步采用Probit模型、集中指数和集中指数分解法对研究结果进行分析。  结果  农村和城市糖尿病家庭灾难性卫生支出发生率分别为16.10 %和21.98 %,无慢性病家庭的9.73 %和12.47 %,同时相对差距与绝对差距也均高于无慢性病家庭;城市和农村糖尿病家庭灾难性卫生支出的集中指数分别为 – 0.287和 – 0.381,而无慢性病家庭灾难性卫生支出的集中指数为 – 0.535和 – 0.482,显示出强烈的倾向于低收入家庭的不平等;经济水平,是否有老人和卫生服务可及性解释了大部分的不平等。  结论  陕西省糖尿病患者面临较高的灾难性卫生支出发生率和倾向于低收入家庭的不平等。     

中国1990 — 2013年妇幼卫生政策进程系统评价

目的 了解家庭针对孕产妇导致的高额费用以及劳动力丧失采取的应对策略,为中国农村地区发生重大负性事件家庭进行有针对性的扶贫和保障工作提供基础数据。 方法 采用前瞻性研究设计,从2009年6月 — 2015年1月对河北、河南和云南省农村地区共183个孕产妇死亡家庭在知情同意后进行了入户基线调查和1年后的随访调查,收集家庭的收入支出、通过何种措施筹集资金、以及家庭应对措施的相关数据。 结果 每个家庭平均需要支付孕产妇死亡造成的直接费用为27 597元。为弥补高额的直接经济损失,孕产妇死亡发生后短期内,家庭通过亲友接济和借款作为最常使用的应对措施,从不同渠道所筹资金的比例主要为借款53.82 %,医院赔偿23.20 %,亲友接济10.13 %。基线调查1年后家庭以选择减少生活支出和继续借款作为最主要的应对措施。为应对孕产妇死亡造成的严重劳动力损失,家庭通过加入新成员、将新生儿寄养在别人家或者请亲戚帮忙照顾替代原孕产妇的部分职能。 结论 农村家庭通过一系列措施来应对孕产妇死亡对家庭经济造成的负面影响,形成了一定的应对策略,但这些应对策略可对家庭未来的经济生活产生进一步的影响。     

我国政府公共卫生支出与医疗体系绩效关系的实证分析

文章分析了我国卫生总费用和政府公共卫生支出水平情况.通过国际比较认为我国卫生总费用GDP占比偏低,这表明我国国民的卫生服务消费水平低下.通过研究认为我国政府和社会的公共卫生支出不足是限制我国卫生服务消费水平的主要原因.本文还分析了我国医疗服务体系的绩效情况,认为我国医疗服务体系的绩效与政府公共卫生支出水平关联不大.政府公共卫生支出水平影响医疗体系的服务能力,而医疗体系的绩效水平主要取决于医疗资源的充分利用和合理配置.最后在研究的基础上提出了相应的政策建议.     

中国公共卫生财政支出分析

本文对我国新医改以来的公共卫生财政支出进行分析,发现主要存在以下问题：一是公共卫生纵向与横向投入不协同,不利于提升专业公共卫生机构在我国公共卫生体系中的地位;二是公共卫生领域的事权与支出责任划分,不利于“预防为主”目标的实现;三是专业公共卫生机构在卫生服务体系中的地位日益弱化,与“预防为主”的要求不相适应;四是人员激励不足,进一步弱化了专业公共卫生机构。据此,本文提出四点政策建议：一是提高公共卫生预算的优先层级,强化公共卫生财政支出的硬约束;二是优化公共卫生财政支出结构,加强公共卫生纵向投入与横向投入的协同;三是完善公共卫生领域的中央和地方事权与支出责任,增强中央财政在横向投入中的支出责任;四是进一步健全人员激励机制,稳步强化专业公共卫生机构。     

The role of private medical practitioners and their interactions with public health services in Asian countries

This paper aims to review the role of private practitioners and their interactions with public health services in developing countries, focusing largely on the Asian region. Evidence on the distribution of health facilities, manpower, health expenditures and utilization rates shows that private practitioners are significant health care providers in many Asian countries. Limited information has been published on interactions between public and private providers despite their co-existence. Issues related to enforcement of regulations, human resources, patient referrals and disease notifications, are examined.