政府卫生支出效率及其改进研究
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摘要
基本医疗卫生服务关系到人们的健康，是重大民生问题。面对卫生事业发展严重滞后于经济发展的局面，我国规划在2020年实现“人人享有基本医疗卫生服务”的目标。政府希望通过新一轮医疗卫生改革的推进尽快达到这个目标。新医改方针定位于“政府主导”，并将政府卫生支出作为“政府主导”的重要渠道，明确提出要建立政府主导的多元卫生投入机制。新医改推行至今3年，政府卫生支出增长很快，但其迅速增长的规模是否适度？其结构配置和资金的具体使用是否有效率？整个政府卫生支出是否带来了显著的健康改善？这已成为各界关注的焦点。研究政府卫生支出的效率及其改进对于基本医疗卫生服务共享目标顺利实施和社会经济包容性增长的实现有重要的理论和现实意义。
在新医改方案推进初期，本文结合公共经济学与卫生经济学的相关理论，选择健康改善的视角，在构建政府卫生支出效率体系的基础上，建立本文的理论分析框架，从经济增长、财政分权、人口特征等方面分析政府卫生支出效率的影响机制并对此进行全面的实证检验。通过系统研究我国政府卫生支出的规模效率、城乡结构效率、供需结构效率和健康生产效率，本文力图为政府部门提供有针对性的政策建议，为建立覆盖城乡居民的基本医疗卫生服务体系、改善人们健康，达到人人享有基本医疗卫生服务的目标提供理论和政策支撑。
首先，本文在系统梳理国内外相关研究成果的基础上，从规模效率、结构效率、生产效率三个层次构建了政府卫生支出效率体系，并选择经济增长、财政分权、人口特征三个方面对政府卫生支出效率的影响机制进行研究，从而构建统一的分析框架与理论平台。其中，经济增长通过影响政府卫生支出供给、政府卫生支出需求和技术进步来影响政府卫生支出效率；财政分权通过政府竞争、地方政府的信息优势和财权事权分配来影响政府卫生支出效率；人口特征则主要通过人口规模、人口结构和人口素质影响政府卫生支出效率。
其次，本文着重对政府卫生支出的规模效率、城乡结构效率、供需结构效率和健康生产效率的影响因素进行了全面的实证检验。论文使用面板数据建立政府卫生支出规模效率的影响因素模型，发现对政府卫生支出规模效率影响最大的是经济增长和财政分权。其中经济增长对政府卫生支出规模效率有显著促进作用，而财政分权对其具有显著负向影响。其他有较显著正向影响的因素有环境污染、城镇化率和住院分娩率。论文使用偏最小二乘回归法检验了政府卫生支出城乡结构效率和供需结构效率的影响因素，发现政策因素、经济增长、卫生因素（传染病死亡率、传染病发生率、每千农村人口卫生技术人员数及医疗机构床位数）有利于提高城乡结构效率，而财政分权和环境污染则不利于提高城乡结构效率；有利于提高政府卫生支出供需结构效率的因素有经济增长、卫生因素（每千人口医疗机构床位数及卫生技术人员数）和人口素质等，不利于提高供需结构效率的因素有城镇化水平和传染病发生率。政府卫生支出健康生产效率的影响因素研究则发现，财政分权不利于健康生产效率的提高，而经济增长、人口密度及城市化率则与其存在不显著的正相关关系。上述实证分析验证了前文的理论分析。
此外，在政府卫生支出规模效率分析中，本文通过建立政府卫生支出最优规模的生产函数模型，指出中国政府卫生支出具有生产性，其增长可以促进经济增长；中国政府卫生支出的最优规模是占GDP的9.6%，由此判断目前中国政府卫生支出规模仍可以适度增长。在政府卫生支出结构效率分析中，本文采用区域城乡双维度泰尔指数对政府卫生支出城乡结构的均等性水平进行了测算，结果显示城乡政府卫生支出不均等是我国政府卫生支出不均等的主要原因；本部分还发现政府卫生支出城乡差异在高分位数上对城乡收入差距有显著影响。本文使用DEA方法对1990年、2000年和2010年政府卫生支出健康生产效率进行了测算，发现不同年度处于前沿面的省份基本一致，远离前沿面的省份存在较大差别，总体而言政府卫生支出的健康产出效率不断提高，且该效率在区域间的差异较为显著。
基于上述理论分析与实证检验，本文从完善财政分权制度、保障政府卫生支出规模适度增长、优化政府卫生支出结构效率和提高政府卫生支出健康生产效率等四个方面提出了改进政府卫生支出效率的相关政策建议，希望能为政府拟定有效的卫生政策，建立覆盖城乡居民的基本医疗卫生服务体系提供政策支撑。
The basic health care service is an important livelihood issue in China, whichconcerns the population health. As health care is lagging behind economicdevelopment in China, the government plans to achieve the goal of “universal basichealth care coverage” by2020through implementing the new round health carereform. The proposal for this reform centers around the dominant role of government,which sets the government health spending as the key channel of this dominance andexplicitly put forward the objective to establish a multi-resource fund system. Withthe new health care reform being implementing for3years up until now, thegovernment health spending grows fast in real terms. However, there are still quite afew questions to be addressed, i.e. whether the scale of government health spending isappropriate; whether the structure distribution is effective; whether the fund is usedefficiently and whether the whole input of government spending on health brings theimprovement of population health. All these concerns people working in differentareas. The research of this topic “the efficiency of government health spending and itsimprovement” will have pivotal theoretic and policy implications for the achievementof the goal of the universal basic health care coverage and the inclusive growth ofsocial economic development in China.
This background that the implementation of the reform is still at its initial stageprovides the author an ideal opportunity to explore the issues mentioned above.Integrating the theories of public economics and health economics and choosing theperspective of health improvement, this paper establishes a theoretical framework andanalyses the determinants of government health spending efficiency in terms ofeconomic growth, fiscal decentralization, demographical characteristics etc. byempirical approaches, which is based on the analysis of a system of governmenthealth spending efficiency. By systematically studying of the scale efficiency,structural efficiency (between rural and urban areas and between supply and demandside respectively) and productive efficiency of government health spending, theauthor attempts to draw some policy implications of providing a theoretical andpolicy foundation for the establishment of a basic health care system covering ruraland urban residents, improving the population health and achieving the goal ofuniversal coverage of health care.
Firstly, this paper studies related literatures both home and abroad, andestablishes a system of government health spending efficiency from three aspects, i.e.scale efficiency, structural efficiency and productive efficiency. Under this basis, itinvestigates the theoretical mechanism for the determinants of scale efficiency,structural efficiency and productive efficiency of government health spending interms of economic growth, fiscal decentralization system and demographiccharacteristics and establishes a unitary analyzing framework and theoretic platform.Economic growth has an impact on the efficiency of government health spendingthrough the supply side effects, demand side effects and technology progress effects;The impacts of fiscal decentralization on government health spending can be achievedby the competition among governments, information symmetry and the distribution offinancial resources; The impacts of demographical characteristics, however, comefrom its influence on the scale, structure and quality of the population.
Secondly, this paper does a comprehensive empirical study of the determinants ofthe scale efficiency, structural efficiency and productive efficiency of governmenthealth spending. Using panel data approach, this paper establishes a determinantsmodel of scale efficiency of government health spending. Economic growth and fiscaldecentralization are found to be the most important determinants of governmenthealth spending: Economic growth has a significant positive impact and fiscaldecentralization has a significant negative impact on government health spending.The other significant positive factors include environmental factor, urbanization rate,and hospital delivery rate. The determinants of structural efficiency of governmenthealth spending between rural area and urban area are investigated using biased OLSapproach. Policy measures, economic growth, mortality rate, medical technicalpersonnel in health care institutions per thousand persons in rural areas, the number ofbeds in health care institutions and incidence rate of infectious disease have asignificant negative impact on the structural efficiency of government health spendingbetween rural area and urban area. However, fiscal decentralization andenvironmental factor have positive impacts on the structure ratio, which is to thedisadvantage of improvement of structural efficiency between rural area and urbanarea. In analyzing the determinants of structural efficiency of government healthspending between supply and demand side, economic growth, the number of beds inhealth care institutions and environmental factor are found to have a positive impacton the improvement of structural efficiency between supply and demand sides.Urbanization rate and infectious disease mortality rate can lead to the reduction of this efficiency rate. The results of the determinants of health productive efficiency ofgovernment health spending turns out to be that fiscal decentralization has significantnegative impacts on health productive efficiency. Economic growth, urbanization rateand population density are found to have insignificant positive impact. All theseempirical analyses fit with the theoretical analysis in the previous part.
Furthermore, in the analysis of scale efficiency of government health spending,the author establishes a production model in order to calculate the optimal scale ofgovernment health spending in China. The empirical results demonstrate thatgovernment health spending in China is productive, which has a positive impact oneconomic growth; the optimal scale of government health spending is9.6%of GDP,based on which a conclusion is drawn that there can still be a moderate growth ingovernment health spending. In the part of structural efficiency analysis, the authorgauges the inequality of government health spending between rural and urban areas byusing Theil index and finds out that the inequalities in rural and urban areas is themain reason of inequalities in China. The author also finds that government healthspending discrepancy between rural and urban areas have different impact on theincome gap between rural and urban areas in high quartiles. DEA approach is used tocalculate the health productive efficiency in1990,2000and2010respectively. Thesame provinces are found to be on the productive frontier, but the provinces off thefrontier are different. In general, health productive efficiency of government healthspending is increasing gradually, and the regional difference in efficiency issignificant.
Lastly, based on the theoretical and empirical analysis above, this paper putsforward corresponding policy suggestions of improving the efficiency of governmenthealth spending from four perspectives, i.e. ensuring the moderate growth ofgovernment health spending, optimizing the structural efficiency of governmenthealth spending, improving the health productive efficiency and completing thesystem of fiscal decentralization, in hope of supporting the government policy indesigning effective health policies and establishing basic health care system coveringthe rural and urban areas.
在新医改方案推进初期，本文结合公共经济学与卫生经济学的相关理论，选择健康改善的视角，在构建政府卫生支出效率体系的基础上，建立本文的理论分析框架，从经济增长、财政分权、人口特征等方面分析政府卫生支出效率的影响机制并对此进行全面的实证检验。通过系统研究我国政府卫生支出的规模效率、城乡结构效率、供需结构效率和健康生产效率，本文力图为政府部门提供有针对性的政策建议，为建立覆盖城乡居民的基本医疗卫生服务体系、改善人们健康，达到人人享有基本医疗卫生服务的目标提供理论和政策支撑。
首先，本文在系统梳理国内外相关研究成果的基础上，从规模效率、结构效率、生产效率三个层次构建了政府卫生支出效率体系，并选择经济增长、财政分权、人口特征三个方面对政府卫生支出效率的影响机制进行研究，从而构建统一的分析框架与理论平台。其中，经济增长通过影响政府卫生支出供给、政府卫生支出需求和技术进步来影响政府卫生支出效率；财政分权通过政府竞争、地方政府的信息优势和财权事权分配来影响政府卫生支出效率；人口特征则主要通过人口规模、人口结构和人口素质影响政府卫生支出效率。
其次，本文着重对政府卫生支出的规模效率、城乡结构效率、供需结构效率和健康生产效率的影响因素进行了全面的实证检验。论文使用面板数据建立政府卫生支出规模效率的影响因素模型，发现对政府卫生支出规模效率影响最大的是经济增长和财政分权。其中经济增长对政府卫生支出规模效率有显著促进作用，而财政分权对其具有显著负向影响。其他有较显著正向影响的因素有环境污染、城镇化率和住院分娩率。论文使用偏最小二乘回归法检验了政府卫生支出城乡结构效率和供需结构效率的影响因素，发现政策因素、经济增长、卫生因素（传染病死亡率、传染病发生率、每千农村人口卫生技术人员数及医疗机构床位数）有利于提高城乡结构效率，而财政分权和环境污染则不利于提高城乡结构效率；有利于提高政府卫生支出供需结构效率的因素有经济增长、卫生因素（每千人口医疗机构床位数及卫生技术人员数）和人口素质等，不利于提高供需结构效率的因素有城镇化水平和传染病发生率。政府卫生支出健康生产效率的影响因素研究则发现，财政分权不利于健康生产效率的提高，而经济增长、人口密度及城市化率则与其存在不显著的正相关关系。上述实证分析验证了前文的理论分析。
此外，在政府卫生支出规模效率分析中，本文通过建立政府卫生支出最优规模的生产函数模型，指出中国政府卫生支出具有生产性，其增长可以促进经济增长；中国政府卫生支出的最优规模是占GDP的9.6%，由此判断目前中国政府卫生支出规模仍可以适度增长。在政府卫生支出结构效率分析中，本文采用区域城乡双维度泰尔指数对政府卫生支出城乡结构的均等性水平进行了测算，结果显示城乡政府卫生支出不均等是我国政府卫生支出不均等的主要原因；本部分还发现政府卫生支出城乡差异在高分位数上对城乡收入差距有显著影响。本文使用DEA方法对1990年、2000年和2010年政府卫生支出健康生产效率进行了测算，发现不同年度处于前沿面的省份基本一致，远离前沿面的省份存在较大差别，总体而言政府卫生支出的健康产出效率不断提高，且该效率在区域间的差异较为显著。
基于上述理论分析与实证检验，本文从完善财政分权制度、保障政府卫生支出规模适度增长、优化政府卫生支出结构效率和提高政府卫生支出健康生产效率等四个方面提出了改进政府卫生支出效率的相关政策建议，希望能为政府拟定有效的卫生政策，建立覆盖城乡居民的基本医疗卫生服务体系提供政策支撑。
The basic health care service is an important livelihood issue in China, whichconcerns the population health. As health care is lagging behind economicdevelopment in China, the government plans to achieve the goal of “universal basichealth care coverage” by2020through implementing the new round health carereform. The proposal for this reform centers around the dominant role of government,which sets the government health spending as the key channel of this dominance andexplicitly put forward the objective to establish a multi-resource fund system. Withthe new health care reform being implementing for3years up until now, thegovernment health spending grows fast in real terms. However, there are still quite afew questions to be addressed, i.e. whether the scale of government health spending isappropriate; whether the structure distribution is effective; whether the fund is usedefficiently and whether the whole input of government spending on health brings theimprovement of population health. All these concerns people working in differentareas. The research of this topic “the efficiency of government health spending and itsimprovement” will have pivotal theoretic and policy implications for the achievementof the goal of the universal basic health care coverage and the inclusive growth ofsocial economic development in China.
This background that the implementation of the reform is still at its initial stageprovides the author an ideal opportunity to explore the issues mentioned above.Integrating the theories of public economics and health economics and choosing theperspective of health improvement, this paper establishes a theoretical framework andanalyses the determinants of government health spending efficiency in terms ofeconomic growth, fiscal decentralization, demographical characteristics etc. byempirical approaches, which is based on the analysis of a system of governmenthealth spending efficiency. By systematically studying of the scale efficiency,structural efficiency (between rural and urban areas and between supply and demandside respectively) and productive efficiency of government health spending, theauthor attempts to draw some policy implications of providing a theoretical andpolicy foundation for the establishment of a basic health care system covering ruraland urban residents, improving the population health and achieving the goal ofuniversal coverage of health care.
Firstly, this paper studies related literatures both home and abroad, andestablishes a system of government health spending efficiency from three aspects, i.e.scale efficiency, structural efficiency and productive efficiency. Under this basis, itinvestigates the theoretical mechanism for the determinants of scale efficiency,structural efficiency and productive efficiency of government health spending interms of economic growth, fiscal decentralization system and demographiccharacteristics and establishes a unitary analyzing framework and theoretic platform.Economic growth has an impact on the efficiency of government health spendingthrough the supply side effects, demand side effects and technology progress effects;The impacts of fiscal decentralization on government health spending can be achievedby the competition among governments, information symmetry and the distribution offinancial resources; The impacts of demographical characteristics, however, comefrom its influence on the scale, structure and quality of the population.
Secondly, this paper does a comprehensive empirical study of the determinants ofthe scale efficiency, structural efficiency and productive efficiency of governmenthealth spending. Using panel data approach, this paper establishes a determinantsmodel of scale efficiency of government health spending. Economic growth and fiscaldecentralization are found to be the most important determinants of governmenthealth spending: Economic growth has a significant positive impact and fiscaldecentralization has a significant negative impact on government health spending.The other significant positive factors include environmental factor, urbanization rate,and hospital delivery rate. The determinants of structural efficiency of governmenthealth spending between rural area and urban area are investigated using biased OLSapproach. Policy measures, economic growth, mortality rate, medical technicalpersonnel in health care institutions per thousand persons in rural areas, the number ofbeds in health care institutions and incidence rate of infectious disease have asignificant negative impact on the structural efficiency of government health spendingbetween rural area and urban area. However, fiscal decentralization andenvironmental factor have positive impacts on the structure ratio, which is to thedisadvantage of improvement of structural efficiency between rural area and urbanarea. In analyzing the determinants of structural efficiency of government healthspending between supply and demand side, economic growth, the number of beds inhealth care institutions and environmental factor are found to have a positive impacton the improvement of structural efficiency between supply and demand sides.Urbanization rate and infectious disease mortality rate can lead to the reduction of this efficiency rate. The results of the determinants of health productive efficiency ofgovernment health spending turns out to be that fiscal decentralization has significantnegative impacts on health productive efficiency. Economic growth, urbanization rateand population density are found to have insignificant positive impact. All theseempirical analyses fit with the theoretical analysis in the previous part.
Furthermore, in the analysis of scale efficiency of government health spending,the author establishes a production model in order to calculate the optimal scale ofgovernment health spending in China. The empirical results demonstrate thatgovernment health spending in China is productive, which has a positive impact oneconomic growth; the optimal scale of government health spending is9.6%of GDP,based on which a conclusion is drawn that there can still be a moderate growth ingovernment health spending. In the part of structural efficiency analysis, the authorgauges the inequality of government health spending between rural and urban areas byusing Theil index and finds out that the inequalities in rural and urban areas is themain reason of inequalities in China. The author also finds that government healthspending discrepancy between rural and urban areas have different impact on theincome gap between rural and urban areas in high quartiles. DEA approach is used tocalculate the health productive efficiency in1990,2000and2010respectively. Thesame provinces are found to be on the productive frontier, but the provinces off thefrontier are different. In general, health productive efficiency of government healthspending is increasing gradually, and the regional difference in efficiency issignificant.
Lastly, based on the theoretical and empirical analysis above, this paper putsforward corresponding policy suggestions of improving the efficiency of governmenthealth spending from four perspectives, i.e. ensuring the moderate growth ofgovernment health spending, optimizing the structural efficiency of governmenthealth spending, improving the health productive efficiency and completing thesystem of fiscal decentralization, in hope of supporting the government policy indesigning effective health policies and establishing basic health care system coveringthe rural and urban areas.
引文
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