卫生服务体系整合的发展与实践

通过回顾国际和中国卫生服务体系整合的形式与发展实践,提出了卫生服务体系整合的内涵,阐述了整合的目的与意义以及政策含义。通过辽宁省等地卫生资源整合改革实践的分析,认为卫生服务体系整合不仅可以优化卫生资源配置和改善卫生服务公平性,而且是缓解＂看病贵、看病难＂问题的有效途径;同时,这种上下联动为特征的整合卫生服务体系变革,可以强化基层卫生服务体系建设,推进公立医院改革进程,改善卫生系统绩效。     

Decision makers' views on health care objectives and budget constraints: results from a pilot study

Economic evaluations aim to inform policy makers about the costs and effects of medical interventions to support their decisions on the allocation of health care resources. Decision makers combine information on cost-effectiveness with their preferences and with possible constraints for the allocation of health care resources. That is, decision makers need to specify an optimality criterion and all possible (budget) constraints. Usually this is a more or less implicit process. The aim of our pilot study was to find out whether decision makers consider the objectives and budget constraints we selected for a theoretical model of resource allocation relevant, and to set priorities for these objectives.     

Bio-terrorism,bio-defense,bioethics

The terrorist attacks launched on September 11, 2001, ignited fear of further aggression with biological weapons, leading to a discourse and allocation of resources for both defensive and dissuasive/ offensive use in order to counteract such threats. Many such measures involved the investigation and production of biological agents, and the public health field has been called upon to participate in these strategic efforts. Participation by health programs is in moral contradiction with military tactics and should be limited to protecting the health of the purportedly threatened population, in itself a difficult task due to the numerous imponderable factors. The additional resources being made available to public health are largely conditioned on their strategic military application, leaving traditional public health care in its chronic state of insufficient funding and non-egalitarian allocation.     

Current research perspectives of health system research and health economics in Germany

The German statutory health insurance scheme is confronted with a steadily rapid progress of medical sciences and increasing difficulties to mobilize the financial resources necessary for applying the new scientific knowledge in health care. Therefore it is absolutely imperative to intensify the efforts to improve the effectiveness and efficiency of health care. Health policies based on health targets, the development of patterns requiring integrated care, redefining the bunch of health insurance benefits, and a more regular use of methods of economic evaluation have been proposed as promising approaches towards optimizing resource allocation in health care. However, an analysis of these approaches demonstrates that a valid appraisal of their potential to improve the effectiveness and efficiency of health care requires further research. In addition, European integration may produce tendencies towards a convergence of the national health care systems; this makes it rather difficult to assess how the room for autonomous national health policies will develop in the future.     

Exploring improvement plans of fourteen European integrated care sites for older people with complex needs

Integrated care programmes are increasingly being put in place to provide care to older people living at home. However, knowledge about further improving integrated care is limited. In fourteen integrated care sites in Europe, plans to improve existing ways of working were designed, implemented and evaluated to enlarge the understanding of what works and with what outcomes when improving integrated care. This paper provides insight into the existing ways that the sites were working with respect to integrated care, their perceived difficulties and their plans for working towards improvement. The seven components of the Expanded Chronic Care Model provided a conceptual framework for describing the fourteen sites. Although sites were spread across Europe and differed in basic characteristics and existing ways of working, a number of difficulties in delivering integrated care were similar. Existing ways of working and improvement plans mostly focused on three components of the Expanded Chronic Care Model: delivery system design; decision support; self-management. Two components were represented less frequently in existing ways of working and improvement plans: building healthy public policy; building community capacity. These findings suggest that broadly-based prevention efforts, population health promotion and community involvement remain limited. From the Expanded Chronic Care Model perspective, therefore, opportunities for improving integrated care outcomes may continue to be restricted by the narrow focus of developed improvement plans.     

A Framework for Assessing the Performance of Integrated Health Delivery Systems

Competing demands for resources within the health care system require health care providers to ensure the most effective and efficient use of resources. The evidence from the United States, the United Kingdom and other jurisdictions suggests that integrated health delivery systems (IDS) may be a cost-effective way to meet the health care needs of a population. This article introduces a framework for use in monitoring and evaluating the performance of an integrated delivery system. The establishment of a consistently used evaluation framework for integrated delivery systems will provide the government, governing bodies and other evaluators with an effective assessment tool that will enable greater understanding of the impact of the IDS on the health care system. It will also provide information to enable ongoing performance improvements within the system.     

Equity in the allocation of health care resources

This paper examines some of the issues that arise when seeking to tackle health inequalities in a context of limited health care resources. Increasingly, central agencies are using devolved budgets for health care providers as a central instrument of expenditure control. Equity objectives play an important role in the resource allocation methods used to determine such budgets. Yet, unless integrated into a proper system of risk management, the use of budgets can lead to serious inequity. The paper discusses the potential contributions of different disciplines to promoting equity within a health care budgetary regime.     

上海市2015年—2019年卫生人力资源配置公平性研究

目的 分析2015年—2019年上海市卫生人力资源配置现状及公平性,探讨卫生人才队伍建设过程中存在的问题,为下一阶段合理配置卫生人力资源提供参考依据。方法 对上海市卫生人力资源配置的基本情况进行描述性分析,综合运用基尼系数、泰尔指数、集中指数,从人口、面积2个维度研究卫生人力资源配置的公平性。结果 上海市卫生人力资源总量不断改善,但卫生人力资源配置公平性按人口配置优于按面积配置,卫生人力资源配置区域内与区域间均存在不均衡现象。结论 上海市卫生人力资源配置公平性还需进一步优化,以此改善人口密度与地理面积不均衡带来的卫生人力资源配置不公平问题。     

The role of the architectural environment in community health: an evidence-based initiative.

This discussion reports the status of a 12-year program administered by a statewide health agency to strategically assess, redevelop, and monitor the architectural and facility management performance of its network of community-based public health care facilities. A protocol, the Strategic Facility Improvement initiative, has directly resulted in significant improvements to the major share of a network of over 100 community clinic and clinical support facilities in the State of Louisiana. The SFI initiative provides oversight with respect to the allocation of public health capital improvement infrastructural resources and has guided completion of 55 facility replacement or renovation projects to date. Its administrative mission, organizational structure, and field methodology is presented as a vehicle to significantly improve the architectural condition of clinical and clinical support environments for underrepresented patient populations. The SFI process is discussed as an evidence-based means to foster greater systemic success in capital improvement efforts within public sector health agencies in the United States and in international contexts.     

The integration of public health and medicine

President Clinton's American Health Security Act proposes to reform and integrate the medical care and public health service delivery systems. Historically, there have been examples of efforts to integrate public health and medical activities. Yet, while many have acknowledged the inherent value of such an integrated approach to improving health, the fact is that these efforts have had only limited success. The "new deal" President Clinton has proposed for these health institutions is examined in this context. If the notion of integration is taken seriously--that is to mean the extent to which each system's diverse activities complement each other, fitting together to form an integrated whole--then it will not be easy to achieve. Review of the "visions" of public health and medicine and of examples of efforts to integrate public health and medicine in this country suggest five conditions that must be met if successful integration is to be achieved. While the resources necessary to integrate public health and medicine are great, of equal importance is the acceptance of a shared vision of an integrated health care system, and of the respective roles and responsibilities of public health and medical care in that system. The benefits to our nation's health of proceeding in this way, however, are enormous. As we move into the twenty-first century, an integrated system of public health and medical care services is our nation's best hope for not only improving the health of all our citizens, but for closing the "health gap" between socioeconomically disadvantaged groups and the rest of the population.     

Quality improvement efforts under health reform: how to ensure that they help reduce disparities--not increase them

Despite persistent evidence of continued racial and ethnic disparities in health care, little explicit attention has been paid to how quality improvement activities might affect disparities. As the nation focuses on the practical realities of implementing health care reform and concurrent quality improvement provisions under the Affordable Care Act of 2010, it is important to recognize that overall improvements in the US health care system might not automatically benefit all segments of the population equally. In this article we highlight challenges to ensuring that quality improvement efforts reduce racial and ethnic disparities. These include making certain that quality improvement efforts measure disparities and improvements in them, notwithstanding providers' reputational concerns; that such efforts not create perverse incentives for providers to avoid serving minority patients; that they be applied to institutions where minority patients are most likely to receive care; and that they fully engage minority patients despite language or other barriers. To assist in these efforts, we argue for the development of disparities impact assessments to measure the effect that the Affordable Care Act's quality provisions will have on reducing disparities.     

Safe motherhood professional responsibility,notes from the World Congress of Obstetrics and Gynaecology in Rio de Janeiro

Maternal mortality and morbidity are community diseases which need to be addressed mainly at the community level. As was noted in the 1988 World Congress of Obstetrics and Gynaecology, obstetricians and gynecologists have a social responsibility to promote women's health, with the 1st step being prevention of mortality and morbidity. 2 important facets of prevention are good family planning education and services to prevent high-risk pregnancies and adequate obstetric care. The General Assembly of the International Federation of Gynaecology and Obstetrics, which preceded the Congress, urged governments to ensure adequate nutrition, education and health care for girls; support to family planning within the context of maternal and child health; and expansion of the coverage and improvement of the quality of maternity services. The General Assembly requested its member associations: 1) to advocate and support promotion of women's health and social status and to support governments in establishing national committees involving all relevant sectors of society; 2) to support governments in their efforts to rationalize the allocation of resources to provide essential care for every woman; 3) to provide governments with the necessary technical support in their efforts to expand the availability of essential elements of obstetric care and the necessary technologies associated with them; 4) to promote and support the involvement of obstetricians in action-oriented research aimed at developing and testing innovative approaches to the delivery of maternity care services, including their cost effectiveness; and 5) to act as the focal point for rallying other professional associations and non-governmental organizations, and to collaborate with women's groups for the cause of safe motherhood and improving the health of women in general.     

Spatial access to residential care resources in Beijing, China

ABSTRACT: BACKGROUND: As the population is ageing rapidly in Beijing, the residential care sector is in a fast expansion process with the support of the municipal government. Understanding spatial accessibility to residential care resources by older people supports the need for rational allocation of care resources in future planning. METHODS: Based on population data and data on residential care resources, this study uses two Geographic Information System (GIS) based methods - shortest path analysis and a two-step floating catchment area (2SFCA) method to analyse spatial accessibility to residential care resources. RESULTS: Spatial accessibility varies as the methods and considered factors change. When only time distance is considered, residential care resources are more accessible in the central city than in suburban and exurban areas. If care resources are considered in addition to time distance, spatial accessibility is relatively poor in the central city compared to the northeast to southeast side of the suburban and exurban areas. The resources in the northwest to southwest side of the city are the least accessible, even though several hotspots of residential care resources are located in these areas. CONCLUSIONS: For policy making, it may require combining various methods for a comprehensive analysis. The methods used in this study provide tools for identifying underserved areas in order to improve equity in access to and efficiency in allocation of residential care resources in future planning.     

Distributive justice in medicaid capitation: The evidence from Colorado

In 1995, the state of Colorado began a new funding program for the provision of mental health services to Medicaid recipients. Medicaid funding was restructured from a fee-for-service system into a capitated managed care system. The restructuring altered the way in which mental health resources were allocated within Colorado's mental health system. This article explores the ethical principles inherent in the allocation of mental health resources within Colorado. The allocation system before and after the capitation pilot is analyzed according to three models of distributive justice. Under capitation, access to care corresponds to egalitarian ideals, while service delivery and outcomes follow a more utilitarian philosophy. Results from several empirical studies of the Colorado Medicaid system are used to support this ethical analysis. The analysis leads to the suggestion that the fair-opportunity rule may be a useful principle for developing just distribution systems in other states in the future.     

Strategic costs and preferences revelation in the allocation of resources for health care

This article examines the resources allocation process in the internal market for health care in an environment characterised by asymmetry of information. We analyse the strategic behaviour of the provider and show how, by misreporting its cost function and reservation utility, it might shift the allocation of resources away from the purchaser’s objectives. Although the fundamental importance of equity, efficiency and risk aversion considerations which have been the traditional focus of the literature on allocation of resources should not be denied, this paper shows that contracts and internal markets are not neutral instruments and more research should be devoted to studying their effects.     

Developing effective policy and practice for health promotion in Scotland

Scotland has recently embarked on a new phase of policy and infrastructure development for improving population health and reducing health inequalities that broadly conforms to the Ottawa Charter and WHO's strategic framework for the prevention and control of non-communicable diseases. The new phase is characterised by an integrated, cross-government approach to improving health with strengthened political and Scottish Executive leadership and investment since devolution. A comprehensive policy framework for improving young people's health and reducing inequalities has been developed across education, health, environment and social justice. It builds on an earlier phase of relative stability and continuity in the health promotion infrastructure with policy focused on CVD and cancer prevention and tackling the behavioural risk factors (smoking, alcohol, diet, physical activity) as well as sexual health and mental health and wellbeing. These national strategies are currently being implemented across Scotland. They combine promotion, prevention, treatment and protection goals and target both population-level and high-risk groups. Crosscutting government objectives and headline targets for addressing poverty, disadvantage and health inequalities now supplement the NHS health improvement targets on smoking, alcohol, physical activity, teenage pregnancy and child immunization. Within the health service, prevention efforts are largely concerned with primary care development (anticipatory care) and health system reform to maximize their impact on reducing health inequalities. Efforts to tackle the social determinants of health and reduce inequalities in health outcomes are beginning to be connected and mainstreamed across local government with Community Planning Partnerships as the main vehicle. National level mechanisms for integrated funding, planning and performance reporting to deliver shared priority outcomes have yet to be developed. The development of health improvement strategies has been founded upon a rich source of population health data to monitor changes and improvements, epidemiological studies and evaluation work. The key issues have been to find ways of intervening to accelerate the rate of improvement and to stem the growing health inequalities. A further challenge is to ensure that the lessons from reviews and evaluations of past programmes and strategies are not lost, but help to guide improvements in the complex delivery system and to inform future policy direction. Within the health service, prevention efforts are largely concerned with primary care development and health system reform. Efforts to reduce inequalities in health outcomes are beginning to be connected and mainstreamed across local government.     

Dialogue boxes: a tool for collaborative process evaluation

Process evaluation is now a core component of health promotion program evaluations. Over the past decade, considerable attention and resources were devoted to developing sensitive and collaborative process evaluation methodologies. These efforts share the broad commitments that process evaluation should (a) support program goals and objectives, (b) lead to program improvement, and (c) whenever possible, develop evaluation capacity among participants. This article describes dialogue boxes, a process evaluation tool that has proven extremely useful in diverse health promotion program and planning efforts. The tool itself is described, along with eight lessons learned about the power of this seemingly simple evaluation method, comments about the challenges of this type of process evaluation, and tips for using dialogue boxes in health promotion planning and programs.     

The organization of regional and integrated healthcare delivery systems: challenges facing Brazil's Unified Health System

This article examines the causes of the segmentation/fragmentation in the healthcare process and the benefits of the constitution of networks set up to rationalize expenditures, optimize resources and ensure care tailored to the needs of the users. Its main purpose is to analyze the current challenges facing Brazil's Unified Health System, in order to promote improved integration between services. Among the challenges, those related to the insufficiency of resources due to low public funding, the training and education processes and their effects on the availability of health professionals to work in the public health system and the difficulties in the decentralization of health services and actions in the context of the Brazilian Federation Pact should be stressed. The paper concludes that, besides the efforts to tackle these challenges, the organization of regionalized networks integrated with the Unified Health System also depends on the improvement of intergovernmental management in the health regions to bolster the agreement on responsibilities among the government areas and the qualification of primary healthcare to coordinate care and ensure its continuity at other levels of the system.     

The search for value: a quality improvement cycle linking process, outcomes, and patient satisfaction

American industry has been implementing continuous quality improvement (CQI) for several years. The business community and accrediting organizations are applying pressure to health care organizations to implement CQI to assure the delivery of cost-effective, quality health care services. In their rush to embrace the demands of industry, health care organizations must realize that many within their ranks long ago adopted the philosophy of CQI without calling it by name. The key is to adapt the concepts of CQI to existing quality improvement efforts rather than simply following a new recipe. By looking primarily at hospital systems like administration and finance, health care organizations may not be significantly addressing the clinical system. Consumers, however, want patient care to be addressed immediately. The author reflects on his experience that process improvement, not personnel change, is the key to successes in health care management.     

Primary care in an underserved rural area: the Goodlark experience in Middle Tennessee

With the assistance of Federal funding and three National Health Service Corps physicians, the Goodlark Rural Health Care System was established during the first 8 months of 1979 in a four-county, medically underserved area of Middle Tennessee. Four primary care clinics and a health screening and weight reduction clinic were initiated, and efforts were made to make the clinics responsive to community needs and complementary to existing area resources.A study of the results of these efforts through December 1981 showed that community acceptance, measured by patients' use of the clinics and satisfaction with the services provided, was generally high; however, one of the small primary care clinics was closed after 1 year because of a continuing decline in patient visits. Many patients continued to follow former patterns of reliance on larger centers for specialized care (and occasionally primary care), using the Goodlark clinics primarily for convenience.The primary care clinic that provided the most comprehensive services and that represented an expansion of an area physician's family practice showed a continuing increase in the number of new- and return-patient visits during the period of the study. Indeed, this clinic generated revenue sufficient to support the remaining clinics in the system, allowing Federal funding to be discontinued. The health screening and weight reduction clinic, however, met with poor community response.Acceptance of nurse practitioners by patients of the primary care clinics was high, and the Goodlark experience suggests that these practitioners may be the most cost-effective providers of primary care in more sparsely populated areas.Innovations in health planning must take into consideration local community factors and previous patterns of health care in order to complement existing health resources. Findings with respect to the Goodlark experience may be worthy of consideration by health planners in other localities.