台湾地区医疗服务体系管理的经验和启示

本文首先介绍了台湾地区卫生行政管理架构与医疗服务体系的基本情况,重点分析了台湾地区医疗服务体系管理的做法及特点,主要包括通过实行"医疗网计划",合理配置医疗卫生资源;发挥健保制度和医院评鉴的协同作用,规范医疗机构行为;通过"公办民营"提高公立医院效率,以公私平等政策鼓励社会力量办医;严格公立医院运行管理等。最后,提出了对我国加强医疗卫生服务体系规划管理的启示。     

A network approach for researching political feasibility of healthcare reform: The case of universal healthcare system in Taiwan

This study evaluates the political feasibility of healthcare reform taking place in Taiwan in the past decade. Since Taiwan adopted National Health Insurance (NHI) in 1995, it has provided coverage for virtually all of the island's citizens. However, the imbalance between expenditure and revenue has resulted in a cycle of unsustainable spending which has necessitated financial reforms and political confrontations. By applying social network analysis, this paper examines multiple types of ties between policy elites and power distribution that have evolved in crucial policy events of the NHI's financial reforms between 1998 and 2010. Data sources include official documents and 62 social network interviews that were held with government officials and related unofficial policy participants. Blockmodeling and multidimensional scaling (MDS) are used to determine the major participants and network structures in the NHI domain, as well as the influential policy actors, based on information transmission, resource exchange, reputation attribution and action-set coalition networks in Taiwan's current political situation. The results show that although both public actors and all medical associations are the leading actors in the NHI reform, without good communication with societal actors, the promotion of reform proposals ends in failure. As a tool of political feasibility evaluation, social network analysis can map the political conflict between policy stakeholders systematically when policy makers pursue the result of policy adoption.     

台湾地区全民健保实施按病种付费的经验及启示简

对台湾地区从1995年3月1日实施全民健康保险以来按病种付费的演变过程做了介绍,描述了“论病例计酬”和“台湾版诊断相关分组”的具体实施方法及其对医疗费用与质量的影响,并从制度层面和医疗机构层面提出推广按病种付费的建议。     

Building institutions for an effective health system: lessons from China's experience with rural health reform

This paper is concerned with the management of health system changes aimed at substantially increasing the access to safe and effective health services. It argues that an effective health sector relies on trust-based relationships between users, providers and funders of health services, and that one of the major challenges governments face is to construct institutional arrangements within which these relationships can be embedded. It presents the case of China, which is implementing an ambitious health reform, drawing on a series of visits to rural counties by the author over a 10-year period. It illustrates how the development of reform strategies has been a response both to the challenges arising from the transition to a market economy and the result of actions by different actors, which have led to the gradual creation of increasingly complex institutions. The overall direction of change has been strongly influenced by the efforts made by the political leadership to manage a transition to a modern economy which provides at least some basic benefits to all. The paper concludes that the key lessons for other countries from China's experience with health system reform are less about the detailed design of specific interventions than about its approach to the management of institution-building in a context of complexity and rapid change.     

全球开始关注卫生体系加强

在过去很长一段时间内,某一具体疾病是主要研究对象,但近几十年特别是2005年以来,许多组织开始参与全球卫生研究并关注卫生体系加强。本文对这一关注产生的原因及方式展开研究。研究采用了过程追踪的定性方法,并对政治层面引发和限制其关注的因素进行分析。研究发现加强卫生体系之所以得到广泛关注,主要是因为：全球卫生的参与者担心卫生体系方面的问题会影响千年发展目标的实现,并担心全球卫生行动可能会给国家卫生体系带来负面影响。此外,许多全球卫生组织已经意识到,薄弱的卫生体系会成为实现组织既定目标的瓶颈。尽管目前有众多的参与者支持加强卫生体系,但这些行动者还未形成有凝聚力的政策联盟。此外,加强卫生体系的概念不清晰,而且加强卫生体系的证据很薄弱。由于全球金融危机、全球卫生政策的不确定性以及一些行动者暂时性地支持等,对加强卫生体系的关注是否具有可持续性,目前尚未有定论。     

The management of health services in Tanzania: a plea for health sector reform

There are essentially four main approaches used in attempts to strengthen the management of health services in developing countries. These are: information system development; management training; use of planning and evaluation methodologies; and, health sector reform. As part of a collaborative research project based in Kisarawe District, Tanzania, we tested the hypothesis that a combination of the first three of these approaches would be sufficient to ensure that decisions and actions were taken to bring about major improvements in the management of health services. It was assumed that the decentralization, which took place as part of the 1982 reorganization of local government responsibilities, had provided managers with sufficient decision-making autonomy to allow them to bring about improvement in health service performance, provided that the other conditions were met. In fact, it was found that despite being presented with clear evidence of serious inefficiencies and inequities in the allocation of health resources, managers were often highly reluctant to decide upon actions which would alleviate the problems in situations where there were potential losers as well as winners, even if the benefits greatly outweighed the costs. This article argues that interventions based solely on training, information systems, or planning and evaluation protocols will make only marginal improvements to health service management, and that changes to the system as a whole are needed in order to provide managers and health professionals with incentives to rectify performance failings. Some ideas for health sector reform, to give managers power and incentives for improving efficiency and quality of care, are put forward. Since it is likely that the systemic problems of the health sector in Tanzania are shared by many other developing countries, the lessons drawn from this study probably have more general applicability.     

荷兰健康保险制度改革经验及启示

文章对荷兰健康保险制度改革的历史过程以及现状进行描述分析,总结荷兰健康保险制度改革的特点：建立基于管理型竞争的强制性私立健康保险;私立保险方竞争获得更多的参保人员;政府对保险方和提供者的行为进行监管并提供相关信息;建立了风险均等化制度,消除不同保险方的风险差异。荷兰健康保险制度改革为我国健康保险制度进一步完善提供一些借鉴：消除不同健康保险制度的差距,保障一致性;建立风险均等化制度,调整不同基金池间的风险;商业保险机构参与经办健康保险管理服务;加强医保第三方对供方行为的制约和监督。     

东欧部分经济转型国家医疗费用支付方式的改革与发展趋势

随着经济全球化趋势的不断增强，许多原来采取单一的计划经济体制的国家正逐步向多元化的经济模式转变，而这些处于经济转型期的国家的卫生保健体制随着经济体制的转轨也正面临着一个全新的、充满挑战的环境，因此这些国家都寻求以新的医疗费用支付方式来取代旧的费用预算体制从而提高医院的绩效。本总结了近年来东欧一些最具代表性的经济转轨国家在医疗费用支付方式改革中的经验与教训，并探讨了医疗费用支付方式的未来发展趋势。     

新加坡公立医院改革的主要做法与启示

在经历了公司化改革及重新加强政府指导和干预后,新加坡公立医院改革开始采用更加精细的工具以强化对公立医院的监管,主要做法包括组建医疗集团、开展病例组合的支付方式改革、加强医院评价和国际认证、促进医疗相关信息的公开共享、加强人力资源建设等。改革的主要特点是通过引入市场机制、加强竞争提高服务质量和效率,但必须在政府的干预控制下,以保障大多数人群的基本医疗卫生服务需求为前提。这一改革的基本原则为我国公立医院改革也提供了良好的借鉴。     

Network resilience in the face of health system reform

Many health systems now use networks as governance structures. Network ‘macroculture’ is the complex of artefacts, espoused values and unarticulated assumptions through which network members coordinate network activities. Knowledge of how network macroculture during 2006–2008 develops is therefore of value for understanding how health networks operate, how health system reforms affect them, and how networks function (and can be used) as governance structures. To examine how quasi-market reforms impact upon health networks' macrocultures we systematically compared longitudinal case studies of these impacts across two care networks, a programme network and a user-experience network in the English NHS. We conducted interviews with key informants, focus groups, non-participant observations of meetings and analyses of key documents. We found that in these networks, artefacts adapted to health system reform faster than espoused values did, and the latter adapted faster than basic underlying assumptions. These findings contribute to knowledge by providing empirical support for theories which hold that changes in networks' core practical activity are what stimulate changes in other aspects of network macroculture. The most powerful way of using network macroculture to manage the formation and operation of health networks therefore appears to be by focusing managerial activity on the ways in which networks produce their core artefacts.     

价值取向与政治博弈:美国医改政策回眸

美国共和民主两党在医改政策方面主要围绕着居民健康与卫生保健的权利,以及政府与市场在医疗服务领域的作用等不同的价值取向展开长期的政治博弈。通过对从罗斯福到奥巴马历任政府医改政策的分析,探讨不同政党在价值选择、政策抉择和基于政府与市场平衡的医改政策。其政策过程表明:政党的价值取向奠定了医改政策的基本点;医改不仅仅是一个经济问题,也是一个利益整合的政治问题;政府主导和市场竞争的有机结合即"有管理的保健"改革策略是当下一种明智的选择。     

21世纪卫生系统改革对卫生经济学发展的影响

该文介绍了发达国家和发展中国家在卫生改革中遇到的问题。前者有：组建医院间“战略联盟”,管理保健市场发展,卫生服务效率、公平性和可及性等。后者有：减少政府的作用,改变公共部门的组织及管理,增加卫生资金的来源及数量。这些问题引起卫生经济学界关注。第二次国际卫生经济学会会议将讨论以下专题：信息不对称及卫生保健组织间关系、卫生保健的选择,卫生及卫生服务的需求,健康及卫生服务的分布,卫生保健的经济学评价,卫生保健市场分析,健康保险,管理保健,卫生服务的产出等18个主题。     

Health systems reforms in Singapore: A qualitative study of key stakeholders

In response to a growing chronic disease burden and ageing population, Singapore implemented Regional Health Systems (RHS) in 2008. In January 2017, the MOH announced that the six RHS clusters would be reorganised into three in 2018. This qualitative study sought to identify the health system challenges, opportunities, and ways forward for the implementation of the RHS. We conducted semi-structured interviews with 35 key informants from RHS clusters, government, academia, and private and voluntary sectors. Integration, innovation, and people-centeredness were identified as the key principles of the RHS. The RHS was described as an opportunity to holistically care for a person across the care continuum, address social determinants of health, develop new models of care, and work with social and community partners. Challenges to RHS implementation included difficulties aligning the goals, values, and priorities of multiple actors, the need for better integration across clusters, differing care capabilities and capacities across partners, healthcare financing structures that may not reflect RHS goals, scalability and evaluation of pilot programmes, and disease-centricity, provider-centricity, and medicalisation in health and healthcare. Suggested ways forward included building relationships between actors to facilitate integration; exploring innovative new models of care; clear long-term/scale-up plans for successful pilots; healthcare financing reforms to meet changing patient and population needs; and developing evaluation systems reflective of RHS principles and priorities.     

我国医疗卫生改革进展与展望

系统回顾了我国医疗卫生改革的过程，目的在于识别改革过程中出现的问题，并对新一轮改革做一些展望：根据一些重要事件和政策发布时间，将我国医疗卫生改革划分为五个阶段，分析发现中国医疗卫生改革总体上是同社会经济领域的其他改革是同步的。     

加拿大卫生改革现状、发展趋势及其对我国的启示

全民医疗保健制度是加拿大卫生体系乃至社会政策的核心,经济起伏下的筹资增减深刻影响到加拿大近二十年卫生发展历程,以公平、公正为基本价值观,构建低成本高效益卫生服务体系,为全民及时提供高质量卫生服务是加拿大卫生改革发展的基本趋势。本文介绍了上世纪后十年和本世纪初十年两阶段的加拿大卫生改革的背景、现状、特征、主题、内容、影响、经验和教训,并从公平、效率和长期性三方面阐述了对我国卫生改革发展的启示。     

卫生体系改革评价研究的进展与实践

卫生体系改革评价对判断改革目标实现程度、完善调整改革政策、促进卫生体系持续发展具有重要意义。本文综述了卫生体系改革评价研究的主要进展与特点;重点介绍了中澳卫生与艾滋病项目"医药卫生体制改革评价研究"的主要内容与发现,总结了新一轮医改的总体进展,并针对几个重点领域进行了专题评价研究。分析了我国开展医改评价研究面临的主要问题,主要有对评价研究重视不够,评价主体比较单一,评价研究的框架和指标体系不够完善,研究方法薄弱,评价信息数据收集困难等。建议将评价研究作为医改过程的必要环节和内容,促进评价的制度化和常态化;树立正确的医改评价理念,将提高人民健康水平作为根本目标;持续完善评价框架和指标体系,重点转向绩效结果评价;加强方法学研究,不断提高政策评价的能力与水平。     

Health reform in Greece: planning and implementation of a national health system

The health system in Greece has for many years been in a state of continuous crisis. The basic aspects of this crisis involve: a fragmented administrative framework; low level of public expenditure; a significant private sector; inadequate hospitals; skewed manpower; and, a low level of primary care. In 1983, the National Health System (ESY) was established, as an effort to improve the above situation. This article presents the context of the ESY and the situation of the health system prior to and after the establishment of the ESY. The conclusion drawn is that many of the goals of the ESY have not been achieved or only partly achieved, and that a number of the above serious problems still persist.     

2000年世界卫生报告:拓展卫生系统绩效的视野

2000年世界卫生组织报告的10周年纪念,为我们提供了一个绝佳的机会,去重新审视报告的发布和随后引发的讨论,这种审视有利于客观地认识和理解各种争议、达成新的共识,并使讨论更有价值和更深入。     

实施卫生投融资改革的初步构想

章提出了通过塑造公立医院的投资主体和产权代表，以明晰产权归属，界定投资权益为抓手，来实施卫生投融资改革的构想，化指出，改革的核心是依托市场机制来提高政府投资效率，推动公立医院的机制转换和快速发展，章最后提出应正确理解这一改革与政府职能转变，医院管理体制改革，多元化办医，医院建立法人治理结构，医院产权制度改革，组建医院集团等的关系。     

简述卫生投融资改革之目的与意义

章结合对上海卫生投融资体制和医院建设的现状分析，提出加快卫生投融资改革具有重要的目的与意义。