宁波市江北区社区卫生服务综合配套改革的政策评价

自上而下的行政命令式的改革是当前社区卫生服务改革的主要方式,其显著的特征就是通过一系列政策的制定来构建新的运行体制。本文从公共政策的制度效益和政策目标效益对宁波江北区的社区卫生服务综合改革做了客观的评价。制度方面,江北区探索建立了"三位一体"的社区卫生服务公益性机制,构建了以全科团队为核心的服务模式,完善了服务的网络体系,强化了公共卫生服务。政策效益方面,社区卫生服务费用下降,利用率提高,质量和效率得到强化,公益性与可及性得到改善,改革初步形成了"同利"机制,综合配套改革的满意度较高。未来改革中,社区卫生服务全科医生人才培养和绩效评价指标改革方面还有待于进一步加强。     

The political development of “Program Realignment”: California’s 1991 mental health care reform

This article reviews the legislative process that resulted in the most significant reform of California’s public mental health system in nearly 25 years. The reform, termed “Program Realignment”, decentralized administrative and fiscal control of the mental health system from the state to the county level. The system prior to Program Realignment is discussed here to reveal an already diverse and decentralized county mental health system, fiscal distress, and general dissatisfaction with the system. From these conditions, the objectives of the relevant political actors arose. By tracing the policy development process of Program Realignment, several independent variables are revealed that help explain how and why this legislation came into being and allow generalization of this case to other states’ experiences. These independent variables are an urgent need for action within a limited time frame, a preexisting knowledge base and well-developed policy networks, a spirit of bipartisan cooperation, and the presence of strong leadership. Preliminary evidence suggests that consolidation of fiscal and programmatic authority at the local level has reduced fragmentation of services and increased fiscal flexibility. However, there is concern that the quality of care offered by the state’s 59 local mental health programs will become increasingly disparate and that increased financial flexibility may not be used to improve services for clients but to save money for local governments. Lessons from California’s experience can alert other states to the pros and cons of this policy approach to providing mental health services and inform policymakers in other states of the steps involved in bringing about such a policy change.     

Historicising involvement: the visibility of user groups in the modernisation of the Chilean Mental Health System

In western mental health systems, the involvement of user organisations has become an important dimension of contemporary policy development. But the processes constituting users as a relevant/irrelevant group have received little investigation, especially outside the English-speaking world. Drawing on Luhmann’s theory of society, this article presents a reconstruction of involvement initiatives in mental health policy in Chile between 1990 and 2005. It is based on 17 oral history interviews with policy-makers, high-level professionals, involved users, ex-users, and family activists, drawing also on relevant policy documents. Five processes are identified. In the early 1990s, the relevance of family groups as care providers in the context of deinstitutionalisation shaped the first encounters between psychiatry and community. Later, user groups became relevant as political supporters of the Mental Health Department’s funding requests, and in their capacity to legitimise decisions on involuntary treatment. The first National User Organisation resulted, in 2001. Its relevance was quickly undermined, however, by the AUGE health reform which restricted the definition of diseases and treatments with reference to evidence and costs. The legitimation of users was no longer needed and efforts to involve them subsided. Thus, we argue that the way in which the mental health system observes the voices of users is less a result of the actual status of users’ organisations than of the changing needs of mental health policy for ‘user representation’. By highlighting the contingency of policy shifts, we suggest that this historical and systemic perspective provides grounds for the strategic irritation and transformation of mental health systems through users’ activism.     

Health politics and policy: survey of U.S. health administration courses

In summary, the vast majority of graduate health administration programs in this country offer a course in health politics and policy. Most of these courses are conducted as a seminar involving class discussions, guest speakers, and student projects. Aside from these generalizations, there is little consensus regarding such matters as course content, objectives, textbooks, and readings. The findings of this survey indicate a crying need in health administration education for a basic textbook or collection of readings on health policy and politics. Such a text should cover the following: 1. Basic information on United States politics and government: our constitutional framework; the presidency; the legislative process; the role of the judiciary; state and local governments; etc. 2. Late 20th century United States political culture: why Americans hate politics and distrust politicians; government as "part of the problem"; the role of the media; the role of lobbyists; campaign financing; increased us of initiatives and referenda; etc. 3. Comparisons of the United States health care system to systems in other countries: Canada, Great Britain, Sweden, Germany, etc. 4. Case studies on traditional health policy issues: Hill-Burton, planning, cost versus access, risk segmentation, rationing, health ethics, etc. 5. Bibliography of suggested readings. A textbook or anthology of this type would provide a solid foundation for a health policy course. Instructors could then add discussion of current events, guest speakers' presentations, and selected readings on emerging issues such as health care reform. In this way the course could be grounded in sound political science theory while also meeting the students' needs for practical insights into health policy issues of the day and their own role as health care executives in influencing the outcome of those policy debates.     

Health policy and mental health.

Health policy can be described as policy directed at the determinants of health, i.e. biological and environmental factors, lifestyle and the health care system. This type of policy now has become a policy objective in an increasing number of countries. In this article mental health is placed in the broad context of this policy. The central question is: can the mental health field grasp the opportunity of a growing interest in prevention and health promotion in general, as major objectives of health policy? Or will it stay more or less isolated from the mainstream of current developments? Answering this question means looking at the conditions of health policy. For health policy it is required that a definition be given of health problems and "causing" conditions. There should further be available intervention possibilities of a preventive and intersectoral character and also preventive strategies. It is stated that there is enough standardized information on mental health problems and experience with community-based research to let mental health participate in drawing up a community diagnosis. It also appears possible to construct an ecological health status model for mental health. Research on the factors in this model shows a shift in focus from risk populations to risk situations, e.g. unemployment, industrial disability, divorce and isolation. Further it is recognized that the search for causal factors is substituted by that for precipitating factors. Social-demographic factors, taken alone, are not precipitating factors. What matters is the combination of an underdeveloped coping mechanism, little social support, and prolonged stressful conditions or sudden stressful events.(ABSTRACT TRUNCATED AT 250 WORDS)     

Health insurance reform in Vietnam: a review of recent developments and future challenges

Vietnam is undertaking health financing reform with a view to achieve universal coverage of health insurance within the coming years. To date, around half of the population is covered with some type of health insurance or prepayment. This review applies a conceptual framework of health financing to provide a coherent assessment of the reforms to date with respect to a set of key policy objectives of health financing, including financial sustainability, efficiency in service provision, and equity in health financing. Based on the assessment, the review discusses the main implications of the reforms focusing on achievements and remaining challenges, the nature of the Vietnamese reforms in an international perspective, and the role of the government. The main lessons from the Vietnamese experiences, from which other reforming countries may draw, are the need for sustained resource mobilization, comprehensive reform involving all functions of the health financing system, and to adopt a long-term view of health insurance reform. Future analysis should include continued evaluation of the reforms in terms of impacts on key outcomes and the political dimensions of health reform.     

关于医疗机构分类管理政策的探讨

作者首先剖析了医疗机构分类管理的政策目标,认为解决医疗补偿机制是核心问题.并提出应该用一整套非营利的制度为公立医院重新定位,应对公立医院制度改革进行系统化的设计,其目的是真正确立医院独立经营的地位.最后提出分类管理的政策难点是法律、政策设计和医院效率问题.     

Improving Scotland's health: time for a fresh approach?

Scotland's health remains the worst in the UK. There are several probable reasons for this. Of those that are amenable to change, health improvement policy has been excessively preoccupied with targeting individuals perceived to be 'at risk' rather than adopting a whole population perspective. Environmental as opposed to behavioural approaches to health improvement have been relatively neglected. To meet the challenge of Scotland's poor health more effectively in the future, new strategic thinking is necessary. Three initial steps are required: recognize that current approaches are inadequate and that fresh ideas are needed; identify the principles that should underlie future strategy development; translate these principles into achievable operational objectives. Five principles of a revitalized strategy to improve the health of Scotland in the future are proposed. These are start early and sustain effort; create a healthy and safe environment; reduce geographical as well as social inequalities in health; adopt an evidence-based approach to public health interventions; use epidemiology to assess need, plan interventions and monitor progress. These principles may then be translated into achievable operational policy and practice objectives.     

Health care reform and social participation]

This article begins by briefly reviewing different forms of citizen participation in the health system. The article then suggests the need for mechanisms for society to control each of the tasks that the health system should perform: defining overall policies, financing, insurance, service provision, and evaluating the effectiveness and efficiency of the system. In general, in the countries of Latin America and the Caribbean, health sector policy formulation continues to be carried out in a centralized manner, with limited involvement by individuals and little adaptation to local realities. The reform processes in the Region are progressing in defining or improving the financing responsibility so as to better reconcile the objectives of equity, efficiency, and freedom of choice. Nevertheless, little has been done to develop instruments for citizens to control the functions of financing and insurance. Appropriate instruments are still lacking for citizens to effectively manage service providers. Among the principal obstacles to citizen participation in the health sector in the Region are: inequality in the distribution of income and other forms of power, an embryonic recognition of the rights of people when they are dealing with public services, limited information concerning those rights and the absence of mechanisms for people to truly exercise them, the weakness with which existing control mechanisms recognize social diversity and incorporate the views of minorities or of the most marginalized groups in society, and weak civic organizations.     

Health policy and mental health

Health policy can be described as policy directed at the determinantsof health, i.e. biological and environmental factors, lifestyleand the health care system. This type of policy now has become a policy objective in anincreasing number of countries. In this article mental health is placed in the broad contextof this policy. The central question is: can the mental healthfield grasp the opportunity of a growing interest in preventionand health promotion in general, as major objectives of healthpolicy? Or will it stay more or less isolated from the mainstreamof current developments? Answering this question means looking at the conditions of healthpolicy. For health policy it is required that a definition begiven of health problems and "causing" conditions. There shouldfurther be available intervention possibilities of a preventiveand intersecloral character and also preventive strategies. It is stated that there is enough standardized information onmental health problems and experience with community-based researchto let mental health participate in drawing up a community diagnosis.It also appears possible to construct an ecological health statusmodel for mental health. Research on the factors in this modelshows a shift in focus from risk populations to risk situations,e.g. unemployment, industrial disability, divorce and isolation.Further it is recognized that the search for causal factorsis substituted by that for precipitating factors. Social-demographicfactors, taken alone, are not precipitating factors. What mattersis the combination of an underdeveloped coping mechanism, littlesocial support, and prolonged stressful conditions or suddenstressful events. Our knowledge on the determinants of mentaldisturbances is growing, but for the sake of credibility weneed more detailed data. The practice of mental health preventionshows an emphasis on mental health education which in most casesconsists of a mild form of group therapy. To become a partnerin the topical health policy debate mental health should also(again) stress the socio-economic factors, as for example isdone in the "Healthy Cities" project. Voluntary organizationscan play an important role in this respect. The conclusion is that mental health prevention has enough knowledgeand skills to take part in the health policy development. Itis hoped that the mental health field takes more initiativeto become a partner in that development.     

新医改背景下利益相关者分析方法的应用现况

利益相关者分析方法作为一种政策分析方法,已广泛应用于西方国家的企业管理与卫生政策改革研究和实践,也为我国卫生改革政策的制定与实施提供新分析视角。文章对我国利益相关者分析方法在卫生领域的应用进行了回顾。     

实现"优质低价"医改目标的政策思路

医药卫生体制三项改革实施已过2年，但总体进展并不理想。如何破解因多方利益冲突产生的相互制肘，事关改革成败。本文聚焦三项改革关键点的医院，就实现医改目标势在必行的医院所有制、体制、机制改革问题提出若干政策思路。     

Beyond integration: challenges for children's mental health

This paper reviews access, outcomes, and quality in the children's mental health system. We contend that a major focal point of future reforms should be at the organization level of care delivery. We identify five areas for intentional policy action to better infuse quality into the system. We also call for building upon the momentum of recent high-visibility reform proposals and for renewed advocacy to advance quality-linked perspectives into the children's mental health system beyond its focus on children with severe emotional disturbances.     

精神卫生服务可及性的相关研究

精神卫生服务可及性作为精神卫生服务政策的基本点,加强对精神卫生服务可及性的研究对于理解和制定精神卫生服务政策具有重要意义.本文主要从概念,研究基础,研究角度和内容,存在的不足四个方面对精神卫生服务可及性的相关研究进行简要概述.     

Health care reform: informing difficult choices

During the last decade, policy makers in a large number of countries have attempted various reforms of their health care systems. Health care reform has been described as a 'global epidemic' (Klein, 1993). All health care reforms consist of very complex policy choices, some of which are examined in this article. After an introductory exploration of ideological issues, the objectives of health care reformers are considered. Three major policy objectives of health care reform are examined: cost containment; efficiency; and, equity. Three types of reform which have been advocated are also considered: public planning; market regulation; and provider-advocated reforms such as a 'basic package' with copayments and alternative means of finance. Finally, appropriate features of efficient health care reform are suggested, addressing explicit policy goals.     

Occupational therapy in mental health: challenges and opportunities

The National Mental Health Policy and National Mental Health Plan published in 1992 provided directions for the reform of mental health services in Australia. They stated that mental health services should be part of the mainstream health system and that integrated mental health programmes should be developed to cover the full range of specialist mental health services, focusing on improved quality of service, the consumers, equity of access, continuity of care and redistribution of resources. The Queensland Mental Health Plan published in 1994 set out specific objectives and strategies for implementing mental health service reform in Queensland. In Queensland there has been a concentration on developing core mental health services involving the reorientation of service delivery from institutions to the community, based on the principles of integration, mainstreaming and regional self-sufficiency. Major restructuring of mental health services is taking place, which has meant changes in service development, organizational structures and work practices. There has been a significant impact on the roles and skills required by the mental health workforce in the context of today's mental health services climate. There is a focus on staff providing individualized assessment and continuing treatment using a case management approach, within a continuum of care. Implications for occupational therapists include developing a generic skill base in preparation for broad-spectrum mental health professional roles while maintaining their professional identity. It is recommended that research be conducted to examine the capacity of occupational therapists to adapt to the changing mental health environment. Copyright © 1999 Whurr Publishers Ltd.     

新医改背景下社区卫生服务若干政策问题的探讨

在新医改政策精神的指导下,医药卫生体制改革进入新阶段,社区卫生服务也面临着新的机遇和挑战。本文从理论层面探讨了社区卫生服务中国家基本药物、信息化建设、绩效考核和人员编制、人才培养以及城乡医疗卫生服务均等化等几大核心问题,对其现有的政策逻辑、面临的问题挑战以及相应的对策建议进行了思考。     

Analysing ‘cultural safety’ in mental health policy reform: lessons from British Columbia,Canada

In response to the mental health disparities experienced by Aboriginal peoples, and related inequities regarding the accessibility to appropriate mental health care, there has been a shift in health policy to endorse ‘By Indigenous for Indigenous’ health care delivery models. In Canada, this has resulted in the creation of new mechanisms for Aboriginal participation in health care planning by health authorities with the goal of fostering culturally safe mental health and addictions care. Yet, there is a growing concern about the effects of neo-liberal cost concerns in health policy on the effective implementation of such progressive reform ideas. Drawing on a critical policy review and ethnographic interviews with four community-based Aboriginal organisations and one health authority, this article uses ‘cultural safety’ as a critical lens to discuss emerging tensions within the context of regional Aboriginal mental health care reform in British Columbia. The findings of this study draw attention to the intersecting ways that dominant socio-historical and political ideologies undermine cultural safety in decision-making and funding practices, thereby creating situations of cultural risk for both Aboriginal people working within the area of Aboriginal mental health and by extension for Aboriginal people who are seeking mental health and addictions care. The insights gained from this research contribute to the ongoing dialogue regarding how to foster culturally safe mental health policy and practice, and for action in the political realm.     

Examining the research base for child mental health services and policy

This article reviews the existing research base for child mental health services and policy. It emphasizes the importance of research that looks at the overall community-based system of care as the unit of analysis, and stresses the need to maintain a systems perspective, even when research is focused on components of the overall system. The review concludes that there is a need for a considerable increase in child mental health services research but also indicates that there has been a recent increase in research that has the potential of building a base to change policy. In particular, a need is identified for well-controlled studies that assess both clinical and cost outcomes and for studies that examine the mega issues of the organization and financing of systems of care.     

Toward an analytical approach to health sector reform

An analytical approach to health sector reform requires definition of the objectives of the health sector. Although a multiplicity of objectives may be appealing, there are compelling analytical reasons for simplicity. It is argued that a health status maximization objective is a widely acceptable choice, which captures most of the important aspects of utility maximization of relevance for health sector reform. Equity can be addressed in the process of aggregating individual outcomes. The widely recognized need for health sector reform in developing countries constitutes, in itself, evidence of the market failures in the health sector. If the market worked, why would we need reform? Given an objective and a justification for reform, analysis should proceed to address measurement questions and intervention strategies. The disability-adjusted life year lost is proposed as a consistent and feasible measure of health. Based on an optimization model of health sector performance in Africa, the paper discusses interventions to improve allocative and technical efficiency. These are broadly characterized as interventions dealing with lack of knowledge and interventions dealing with institutional shortcomings. They lead to different approaches to health sector reform. The paper concludes that we now have a systematic analytical approach to reform, in which tools and methods for addressing information gaps are well developed and need to be more widely applied, while those addressing institutional failures still need further development and application.