全民健康覆盖内涵下城乡居民卫生服务需要和利用现状及其公平性差异研究
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摘要
目的基于全民健康覆盖内涵,分析城乡居民卫生服务需要和利用现状、公平性差异,提出政策建议。方法利用国家第五次卫生服务调查(山东省部分)居民数据(12 006户家庭,33 060例居民,其中城市6 006户家庭,10 391例居民,农村6 000户家庭,22 669例居民),结合收入5分法,比较不同城乡类别、收入居民卫生服务需要和利用及其公平性。结果城市居民的两周患病率、年慢性病患病率高于农村居民,两周就诊率、两周患者就诊率低于农村居民(P<0.05);两组居民住院率比较,差异无统计学意义(P>0.05)。农村居民两周患病率、年慢性病患病率、两周就诊率、住院率随其收入的增加而降低,两周患者就诊率随其收入的增加而升高(P<0.05);城市不同收入居民两周患病率、年慢性病患病率、两周就诊率、两周患者就诊率、住院率比较,差异无统计学意义(P>0.05)。城乡居民卫生服务需要和利用公平性分析发现,集中曲线位于公平线上方的指标分别是城乡两周患病[集中指数(CI)=-0.091 5]、农村两周患病(CI=-0.117 9)、城乡慢性病患病(CI=-0.118 4)、农村慢性病患病(CI=-0.168 2)、城市两周就诊(CI=-0.006 4)、城乡/城市/农村住院利用(CI值分别为-0.094 1、-0.001 5、-0.112 4);集中曲线位于公平线下方的分别是城市两周患病(CI=0.012 9)、城市慢性病患病(CI=0.006 4)、城乡/农村两周就诊(CI值分别为0.062 5、0.080 0)。结论农村低收入居民两周卫生服务需要高于高收入居民,农村居民两周患病、慢性病患病、两周就诊公平性差于城市。仍需强基层,加大基层医疗卫生机构的基础设施建设投入,加强基层全科医生的培养,推行分级诊疗制度和家庭医生签约服务,弥合城乡差异,提高全民卫生服务可获得性。应继续细化医疗保险补偿对象的划分,重点提高农村中低收入居民的补偿水平,加强该人群疾病风险保护,提高全民卫生服务可负担性。
Objective To analyze the needs,utilization and equity of health services among urban and rural residents during the process of achieving universal health coverage,and based on this,to put forward policy recommendations.Methods Data stemmed from the Shandong part of the National Health Services Survey in China,2013.In Shandong,a random sample of 33 060 residents of 12 006 families participated,including 10 391 urban residents of 6 006 families,and 22 669 rural residents of 6 000 families.Quinquepartite method was used to classify the residents' income.The needs,utilization and equity of health services were compared between the urban and rural residents.Results Compared with the rural residents,urban residents demonstrated higher two-week morbidity rate and 12-month chronic disease morbidity rate but lower rates of two-week medical consultation and patients' two-week medical consultation(P<0.05).The difference of 12-month hospitalization rate between urban and rural residents was not significant(P>0.05).The two-week morbidity rate,12-month chronic disease morbidity rate,two-week medical consultation rate and 12-month hospitalization rate decreased with the increase of income in rural residents,patients' two-week medical consultation rate increased of income on rural residents(P<0.05).However,these five indicators did not differ significantly between urban and rural residents by the level of income(P>0.05).The analysis of the needs and equity of health service utilization in urban and rural residents showed that the concentration curves lying above the equity line were two-week morbidity rate of all the residents(CI=-0.091 5),two-week morbidity rate of rural residents(CI =-0.117 9),12-month chronic disease morbidity rate of all the residents(CI=-0.118 4),12-month chronic disease morbidity rate of rural residents(CI=-0.168 2),two-week medical consultation rate of urban residents(CI=-0.006 4),utilization of hospitalization services in all the residents,urban residents and rural residents(CI=-0.094 1,-0.001 5,-0.112 4),and those lying below the equity line were two-week morbidity rate of urban residents(CI=0.012 9),12-month chronic disease morbidity rate of urban residents(CI=0.006 4),two-week medical consultation rate in urban and rural residents(CI=0.062 5,0.080 0).Conclusion The two-week health service needs of low-income rural residents were higher than those of high-income people, and the of two-week sickness, chronic disease and two-week visiting fairness of rural residents were worse than that of urban residents.In view of this,the investment for the construction of infrastructure in primary care should be increased,the training for general practitioners should be strengthened,the implementation of hierarchical medical system and contracted family doctor services should be promoted,in order to narrow the gap of accessibility and utilization of health services between urban and rural residents,and improve the universal access to health services.We should continue to refine the division of medical insurance compensation objects and focus on improving the compensation level of rural low-and middleincome residents, improve the protection of people's disease risk and move towards universal health coverage.
Objective To analyze the needs,utilization and equity of health services among urban and rural residents during the process of achieving universal health coverage,and based on this,to put forward policy recommendations.Methods Data stemmed from the Shandong part of the National Health Services Survey in China,2013.In Shandong,a random sample of 33 060 residents of 12 006 families participated,including 10 391 urban residents of 6 006 families,and 22 669 rural residents of 6 000 families.Quinquepartite method was used to classify the residents' income.The needs,utilization and equity of health services were compared between the urban and rural residents.Results Compared with the rural residents,urban residents demonstrated higher two-week morbidity rate and 12-month chronic disease morbidity rate but lower rates of two-week medical consultation and patients' two-week medical consultation(P<0.05).The difference of 12-month hospitalization rate between urban and rural residents was not significant(P>0.05).The two-week morbidity rate,12-month chronic disease morbidity rate,two-week medical consultation rate and 12-month hospitalization rate decreased with the increase of income in rural residents,patients' two-week medical consultation rate increased of income on rural residents(P<0.05).However,these five indicators did not differ significantly between urban and rural residents by the level of income(P>0.05).The analysis of the needs and equity of health service utilization in urban and rural residents showed that the concentration curves lying above the equity line were two-week morbidity rate of all the residents(CI=-0.091 5),two-week morbidity rate of rural residents(CI =-0.117 9),12-month chronic disease morbidity rate of all the residents(CI=-0.118 4),12-month chronic disease morbidity rate of rural residents(CI=-0.168 2),two-week medical consultation rate of urban residents(CI=-0.006 4),utilization of hospitalization services in all the residents,urban residents and rural residents(CI=-0.094 1,-0.001 5,-0.112 4),and those lying below the equity line were two-week morbidity rate of urban residents(CI=0.012 9),12-month chronic disease morbidity rate of urban residents(CI=0.006 4),two-week medical consultation rate in urban and rural residents(CI=0.062 5,0.080 0).Conclusion The two-week health service needs of low-income rural residents were higher than those of high-income people, and the of two-week sickness, chronic disease and two-week visiting fairness of rural residents were worse than that of urban residents.In view of this,the investment for the construction of infrastructure in primary care should be increased,the training for general practitioners should be strengthened,the implementation of hierarchical medical system and contracted family doctor services should be promoted,in order to narrow the gap of accessibility and utilization of health services between urban and rural residents,and improve the universal access to health services.We should continue to refine the division of medical insurance compensation objects and focus on improving the compensation level of rural low-and middleincome residents, improve the protection of people's disease risk and move towards universal health coverage.
引文
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[11]孙迎春.国外政府跨部门合作机制的探索与研究[J].中国行政管理,2010,26(7):102-105.SUN Y C.Study on the intersectoral cooperation mechanism of foreign governments[J].China Administration,2010,26(7):102-105.
[12]周杨,秦江梅,唐景霞,等.不同医疗保险覆盖人群获得政府医疗补助的受益归属及公平性研究[J].中国全科医学,2016,19(22):2710-2713.DOI:10.3969/j.issn.1007-9572.2016.22.020.ZHOU Y,QIN J M,TANG J X,et al.Benefit incidence and equity of government medical subsidy received by people under different health insurance[J].Chinese General Practice,2016,19(22):2710-2713.DOI:10.3969/j.issn.1007-9572.2016.22.020.
[2]傅卫.迈向全民健康覆盖[J].中国卫生,2017,33(9):36-37.DOI:10.15973/j.cnki.cn11-3708/d.2017.09.013.FU W.Towards universal health coverage[J].China Health,2017,33(9):36-37.DOI:10.15973/j.cnki.cn11-3708/d.2017.09.013.
[3]石光.概念、政策与策略:我国如何实现全民健康覆盖的目标[J].卫生经济研究,2013,30(10):6-8.DOI:10.3969/j.issn.1004-7778.2013.10.002.SHI G.Concept,Policy and Strategy:how can China achieve the goal of universal health coverage[J].Health Economics Research,2013,30(10):6-8.DOI:10.3969/j.issn.1004-7778.2013.10.002.
[4]吴业苗.城乡二元结构的存续与转换:基于城乡一体化公共性向度[J].浙江社会科学,2018,33(4):86-92,158.DOI:10.14167/j.zjss.2018.04.018.WUYM.Theexistenceandtransformationofurban-rural dual structure:based on the public orientation of urban-rural integration[J].Zhejiang Social Science,2018,33(4):86-92,158.DOI:10.14167/j.zjss.2018.04.018.
[5]CHENM,FANGG,WANGL,etal.Whobenefitsfrom government healthcare subsidies?An assessment of the equity of healthcare benefits distribution in China[J].PLoS One,2015,10(3):e0119840.
[6]高广颖,马骋宇,胡星宇,等.新农合大病保险制度对缓解灾难性卫生支出的效果评价[J].社会保障研究,2017,9(2):69-76.DOI:10.3969/j.issn.1674-4802.2017.02.008.GAO G Y,MA C Y,HU X Y,et al.Evaluation of the effect of the new rural cooperative medical insurance system on relieving disastrous health expenditure[J].Social Security Research,2017,9(2):69-76.DOI:10.3969/j.issn.1674-4802.2017.02.008.
[7]曹裴娅,罗会强,吴侃,等.四川省城乡患者选择私人诊所的原因调查及影响因素分析[J].中国全科医学,2017,20(3):347-353.DOI:10.3969/j.issn.1007-9572.2017.03.016.CAO P Y,LUO H Q,WU K,et al.Causes and influential factors of urban and rural patients in Sichuan Province choosing private clinics[J].Chinese General Practice,2017,20(3):347-353.DOI:10.3969/j.issn.1007-9572.2017.03.016.
[8]于贞杰,刘相瑜,李向云,等.基于均等化的产后保健服务利用评价研究[J].中国全科医学,2013,16(34):4037-4040.DOI:DOI:10.3969/j.issn.1007-9572.2013.12.008.YU Z J,LIU X Y,LI X Y,et al.Evaluation on utilization of postpartum health service based on equalization[J].Chinese General Practice,2013,16(34):4037-4040.DOI:10.3969/j.issn.1007-9572.2013.12.008.
[9]程名望,JIN Yanhong,盖庆恩,等.农村减贫:应该更关注教育还是健康?——基于收入增长和差距缩小双重视角的实证[J].经济研究,2014,49(11):130-144.CHENGMW,JINYH,GANQE,etal.Ruralpoverty reduction:should we care more about education or health?——Empirical evidence based on double perspective of income growth and gap reduction[J].Economic research,2014,49(11):130-144.
[10]孟庆跃.全民健康覆盖:从理念到行动[J].中国卫生政策研究,2014,7(2):1-4.DOI:10.3969/j.issn.1674-2982.2014.02.001.MENG Q Y.Universal health coverage:from idea to action[J].China Health Policy Research,2014,7(2):1-4.DOI:10.3969/j.issn.1674-2982.2014.02.001.
[11]孙迎春.国外政府跨部门合作机制的探索与研究[J].中国行政管理,2010,26(7):102-105.SUN Y C.Study on the intersectoral cooperation mechanism of foreign governments[J].China Administration,2010,26(7):102-105.
[12]周杨,秦江梅,唐景霞,等.不同医疗保险覆盖人群获得政府医疗补助的受益归属及公平性研究[J].中国全科医学,2016,19(22):2710-2713.DOI:10.3969/j.issn.1007-9572.2016.22.020.ZHOU Y,QIN J M,TANG J X,et al.Benefit incidence and equity of government medical subsidy received by people under different health insurance[J].Chinese General Practice,2016,19(22):2710-2713.DOI:10.3969/j.issn.1007-9572.2016.22.020.