政党意识形态与卫生政策:英国国民健康服务体系变迁的政治学
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摘要
本文分析英国国民健康服务体系(The National Health Service,NHS)改革和转型中,政党意识形态对医疗政策的影响。医疗卫生在英国一直是各届政府执政的核心议题,随着持有不同意识形态的政党当政,英国的医疗卫生政策发生了很大变化:二战后工党在国家福利主义和集体主义指引下建立旨在体现公平正义的NHS;20世纪70年代末保守党当政后在新自由主义思潮下着重提高NHS的运作效率;90年代末工党重新执政,在社群主义和第三条道路的指导下对NHS进行新的改革。尽管政治体制不同,中国过去几十年的医疗变化大体上也经历了与英国类似的由不同意识形态主导的三阶段,显示了政府不断自我更新、转变观念和意识的过程,然而,我国医疗政策的讨论与制定在过去二三十年被经济和科学原则主导,似乎医疗政策与改革是在政治真空的环境中运行的。本文认为分析中国医疗改革需要纳入政治因素把医疗卫生体制改革的政治变为显学。
The paper examines the politics of healthcare policy making, in particular the impact of political parties and their ideologies on health policies in the National Health Service(NHS) of England. Health care and its reform has always been the central theme in every government's agenda. When the political party with its respective ideology took power, its corresponding health policies changed dramatically:from the founding of NHS with the principle of social justice under the leadership of the labour party after the second world war, to the market reform of NHS with the dominant ideology of neoliberalism under Thatcher government from the late 1970 s, and the recent reforms of NHS with the ideology of communitarianism after the labour retaking power from the end of 1990 s. China's health care transformation over the past several decades has seen a similar three-stage process:from fully state run and financed health care system that represent the socialist ideology, towards more private financing and delivery of health care under the market reform, and a new round of healthcare reform after 2000 s that is attempting to reverse the market character of earlier trajectories. These changes have been accompanied by the shifts in values, ideologies, and governance. Yet, health policy analysis has been dominated by economic and scientific principles. Little attention has been paid to political factors. Through analysing the political factors that influence the NHS, the authors hopes to encourage more researches that consider political factors in China's health policy research.
The paper examines the politics of healthcare policy making, in particular the impact of political parties and their ideologies on health policies in the National Health Service(NHS) of England. Health care and its reform has always been the central theme in every government's agenda. When the political party with its respective ideology took power, its corresponding health policies changed dramatically:from the founding of NHS with the principle of social justice under the leadership of the labour party after the second world war, to the market reform of NHS with the dominant ideology of neoliberalism under Thatcher government from the late 1970 s, and the recent reforms of NHS with the ideology of communitarianism after the labour retaking power from the end of 1990 s. China's health care transformation over the past several decades has seen a similar three-stage process:from fully state run and financed health care system that represent the socialist ideology, towards more private financing and delivery of health care under the market reform, and a new round of healthcare reform after 2000 s that is attempting to reverse the market character of earlier trajectories. These changes have been accompanied by the shifts in values, ideologies, and governance. Yet, health policy analysis has been dominated by economic and scientific principles. Little attention has been paid to political factors. Through analysing the political factors that influence the NHS, the authors hopes to encourage more researches that consider political factors in China's health policy research.
引文
[1]蔡江南.奥巴马医改是面镜子[J].中国社会保障,2013,(11).
[2]罗布·巴戈特.解析医疗卫生政策[M].赵万里译.格致出版社,2012.
[3]任锋,朱旭峰.转型期中国公共意识形态政策的议程设置[J].开放时代,2010,(6).
[4]魏姝.政策类型理论的批判及其中国经验研究[J].甘肃行政学院学报,2012,(2).
[5]谢春艳,胡善联,何江江,王力男,彭颖.整合保健;英国经验对我国社区卫生服务改革的启示[J].中国卫生政策研究,2012,(9).
[6]周靖,张孜孜,朱衡.意识形态与卫生保健政策——兼谈卫生公平与效率的再平衡[J].合肥工业大学学报(社会科学版),2012,(3).
[7]Alvarez-Rosete,Arturo,“Modernising Health Policy Making”,in Alison Hann,Health Policy and Politics,2007.
[8]Baggott,Rob,Judith Allsop,and Kathryn L.Jones,Speaking for Patients and Carers;Health Consumer Groups and the Policy Process.Palgrave Macmillan,2005.
[9]Bambra,Clare,Debbie Fox,and Alex ScottSamuel,“Towards a Politics of Health,”Health Promotion International,2005;20(2),187-193.
[10]Bambra,Clare,Debbie Fox,and Alex ScottSamuel,“A Politics of Health Glossary.”Journal of epidemiology and community health,2007;61(7),571-574.
[11]Bevan,Aneurin,In Place of Fear,London;Heinemann,1952.
[12]Bond,Matthew&Julian Le Grand,“Primary care organizations and the‘Modernization’of the NHS”in Bernard Dowling and Caroline Glendinning,The New Primary Care;Modern,Dependable,Successful?Maidenhead;Open University Press,2003.
[13]Boyd,Nick,“The Impact of the European Union on the NHS,”in Alison Hann,Health Policy and Politics,2007.
[14]Bradby,Hannah,Medical Sociology;An Introduction,Sage Publications Ltd,2008.
[15]Brown,Phyllida,“WHO Urges‘Coverage for All,Not Coverage of Everything’,”the BMJ,1999,available at http;//www.bmj.com/content/318/7194/1305.1.
[16]Buse,Kent,Nicholas Mays,Gillian Walt,Making Health Policy,Open University Press,2005.
[17]Bu Soi,Cristian Silviu,“Health Systems and the Influence of Political Ideologies,”Management in Health,2010;XIV/2,4-6.
[18]Dowling,Bernard and Caroline Glendinning,‘The‘new’primary care;Ideology and performance’,in Bernard Dowling and Caroline Glendinning,The New Primary Care;Modern,Dependable,Successful?Maidenhead;Open University Press,2003.
[19]Duckett,Jane.The Chinese State’s Retreat from Health;Policy and the Politics of Retrenchment,London;Routledge,2011.
[20]Engstroem,Timothy and Wade Robison(ed.),Health Care Reform;Ethics and Politics,University of Rochester Press,2006.
[21]Eriksen,Thomas Hylland.Small Places,Large Issues;An Introduction to Social and Cultural Anthropology.Pluto Press,2001.
[22]Espelt,Albert,Carme Borrell,Maica RodriguezSanz,Carles Muntaner,M Isabel Pasarín,Joan Benach,Maartje Schaap,Anton E Kunst,and Vicente Navarro,“Inequalities in health by social class dimensions in European countries of different political traditions”,International Journal of Epidemiology,2008;37(5),1095-105.
[23]Fukuyama,Francis,The End of History and the Last Man,New York;Avon Books,1992.
[24]Gupta,Vin,Vanessa B.Kerry,Eric Goosby,and Robert Yates.“Politics and Universal Health Coverage—The Post-2015 Global Health Agenda.”New England Journal of Medicine.2015:373,(13):1189-1192.
[25]Hann,Alison,Health Policy and Politics,Ashgate Publishing,2007.
[26]Harrison,Stephen,and Ruth Mc Donald.The Politics of Healthcare in Britain,Sage Publications Ltd,2008.
[27]Hunter,David,The Health Debate,The Policy Press,2008.
[28]Hunter DJ,Williams G.NHS“reform”in England:where is the public interest?BMJ 2012;344;e2014.
[29]Hunter,David,“Role of Politics in Understanding Complex,Messy Health Systems;An Essay,”BMJ,2015;350,h1214.
[30]Hunter DJ.Change of government;one more big bang health care reform in England’s National Health Service.Int J Health Serv 2011;41;159-74.
[31]Klein,Rudolf,The New Politics of the NHS;From Creation to Reinvention,Radcliffe Publishing,2006.
[32]Kornreich,Yoel,Ilan Vertinsky,and Pitman B.Potter,“Consultation and Deliberation in China;The Making of China's Health-Care Reform,”China Journal,2012:68,176-203.
[33]Lowi,Theodore J.American Business,Public Policy,Case Studies,and Political Theory.World Politics,1964,16(4).
[34]Lundberg,Olle,Commentary:politics and public health some conceptual considerations concerning welf are state characteristics and public health outcomes,International Journal of Epidemiology,2008:37 5),1105-8.
[35]Lundberg,Olle,“Politics and public health some conceptual considerations concerning welfare state characteristics and public health outcomes”,International Journal of Epidemiology,2010:39(3),632-4.
[36]Morone,James,“Introduction:Health Politics and Policy”,in Morone,Litman&Robins(eds.)Health Politics and Policy,2008,4th edition,1-22.
[37]Muntaner,Carles,Carme Borrell,Edwin Ng,Haejoo Chung,Albert Espelt,Maica Rodriguez-Sanz,Joan Benach and Patricia O’Campo,“Review article:Politics,welfare regimes,and population health:controversies and evidence,”Sociology of Health&Illness,2011:33(6),946-964.
[38]Navarro,Vicente(ed.),The Political and Social Contexts of Health.Baywood Publishing Company,Inc.,2004.
[39]Navarro,Vicente,Carles Muntaner,Carme Borrell,Joan Benach,Agueda Quiroga,Maica RodríguezSanz,Núria Vergés,M Isabel Pasarín,“Politics and Health Outcomes,”The Lancet,2006:368,1033-37.
[40]Pollock,Allyson,NHS plc:The Privatisation of Our Health Care,Verso Books,2005.
[41]Pollock,Allyson,“NHS Privatisation Keeps on Failing Patients Despite a Decade of Warnings”,the Guardian,2014,available at http://www.theguardian.com/commentisfree/2014/aug/15/nhs-privatisation-failing-patients-warnings.
[42]Purdy,Michael and David Banks(ed.),The Sociology and Politics of Health:A Reader,Routledge,2001.
[43]Roberts M,Hsiao William,Berman P,Reich M.Getting health reform right:a guide to improving performance and equity.Oxford:Oxford University Press,2008.
[44]Shaw,Mary,Danny Dorling,David Gordon,George Davey,The Widening Gap:Health Inequalities and Policy in Britain,The Policy Press,1999.
[45]Walt,Gill,and Patrick Vaughan.“Politics of health planning.”World Health Forum,vol.7,no.1,pp.44-9.1986.
[46]Walt,Gill,Health Policy:An Introduction to Process and Power,London:Zed Books,1994.
[47]Webster,Charles,The NHS:A Political History,Oxford:Oxford University Press,2002.
1如巴戈特(2012)提出研究开始转变到关注医疗卫生议题的出现、政策的形成及其贯彻实施背后的政治过程。
2 Marx&Engels在The German Ideology里表示意识形态是一系列源自物质条件的错误的观念,这些观念代表统治阶级的利益。Lenin在What Is To Be Done?里表示意识形态是阶级斗争中一个有用的武器,它可以被各方利用来促进他们的利益,而不论这些观念的真假。Gramsci在Selections from the Prison Notebooks 1929一书里表示意识形态是社会形成的有机和必要部分,意识形态可以把不同群体和不同观念结合到一起,从这个意义上说它是社会粘合剂。占霸权地位的意识形态往往把互相竞争的意识形态的部分结合到一起,因此把多个社会群体的利益也融合到一块。而Althusser在Lenin and Philosophy and other essays一书里指出意识形态是人类社会的基本的元素,是人类历史呼吸和生命的氛围。意识形态在各种社会形态中无所不在,它被用来把社会粘合到一起。(引自Bambra,Fox,and Scott-Samuel,2007)。
3 他们进一步指出:自由主义者认为国家的政治、经济、社会生活,应以维护个人自由为最终目的,国家的作用不是干涉或支配个人的生活,而是以法律为手段维护秩序;平等主义是基于所有个人要求在社会上的平等政治主张,以及所有人应平等地得到社会的保障,包括法律权利、政治权利、公民权利的平等。
4 如上议院David Owen发起的NHS2015年恢复法案运动(The Campaign for the NHS Reinstatement Bill2015),推动在2015年5月有足够的议员回到议会中,让无论哪个政党或政党联盟新组成的政府把医疗服务市场化从2012年健康与社会保健法案中剔除出去。2014年12 月,David Owen出版了新书《民族的健康;NHS在危机中》(The Health of the Nation;NHS in Peril),详述2012年健康与社会保健法案造成的破坏以及废除议案中最坏部分的原因,并提出计划如何可行地让NHS重新回归公益性。
5 广大公众和医务人员开始参与反对私有化NHS的运动,要求NHS的承包合同留在公共领域,反对关闭医院、取消服务和裁减人员,并游说议员,发起了“保留NHS公有”(KONP-Keep Our NHS Public)的运动参看运动官网http;//www.keepournhspublic.com/index.php。
6 罗布·巴戈特列举出英国NHS借鉴其他卫生保健系统的几项重要改革;国家医疗卫生服务信托基金会的创立受到来自西班牙、瑞典以及丹麦类似机构的启迪;委托服务的引入学习了采用市场导向路径卫生保健的国家(比如美国);用私营部门来补充国家卫生保健受到了采取多元方式运营医疗体系的欧洲大陆国家的影响(比如德国与荷兰)。
[2]罗布·巴戈特.解析医疗卫生政策[M].赵万里译.格致出版社,2012.
[3]任锋,朱旭峰.转型期中国公共意识形态政策的议程设置[J].开放时代,2010,(6).
[4]魏姝.政策类型理论的批判及其中国经验研究[J].甘肃行政学院学报,2012,(2).
[5]谢春艳,胡善联,何江江,王力男,彭颖.整合保健;英国经验对我国社区卫生服务改革的启示[J].中国卫生政策研究,2012,(9).
[6]周靖,张孜孜,朱衡.意识形态与卫生保健政策——兼谈卫生公平与效率的再平衡[J].合肥工业大学学报(社会科学版),2012,(3).
[7]Alvarez-Rosete,Arturo,“Modernising Health Policy Making”,in Alison Hann,Health Policy and Politics,2007.
[8]Baggott,Rob,Judith Allsop,and Kathryn L.Jones,Speaking for Patients and Carers;Health Consumer Groups and the Policy Process.Palgrave Macmillan,2005.
[9]Bambra,Clare,Debbie Fox,and Alex ScottSamuel,“Towards a Politics of Health,”Health Promotion International,2005;20(2),187-193.
[10]Bambra,Clare,Debbie Fox,and Alex ScottSamuel,“A Politics of Health Glossary.”Journal of epidemiology and community health,2007;61(7),571-574.
[11]Bevan,Aneurin,In Place of Fear,London;Heinemann,1952.
[12]Bond,Matthew&Julian Le Grand,“Primary care organizations and the‘Modernization’of the NHS”in Bernard Dowling and Caroline Glendinning,The New Primary Care;Modern,Dependable,Successful?Maidenhead;Open University Press,2003.
[13]Boyd,Nick,“The Impact of the European Union on the NHS,”in Alison Hann,Health Policy and Politics,2007.
[14]Bradby,Hannah,Medical Sociology;An Introduction,Sage Publications Ltd,2008.
[15]Brown,Phyllida,“WHO Urges‘Coverage for All,Not Coverage of Everything’,”the BMJ,1999,available at http;//www.bmj.com/content/318/7194/1305.1.
[16]Buse,Kent,Nicholas Mays,Gillian Walt,Making Health Policy,Open University Press,2005.
[17]Bu Soi,Cristian Silviu,“Health Systems and the Influence of Political Ideologies,”Management in Health,2010;XIV/2,4-6.
[18]Dowling,Bernard and Caroline Glendinning,‘The‘new’primary care;Ideology and performance’,in Bernard Dowling and Caroline Glendinning,The New Primary Care;Modern,Dependable,Successful?Maidenhead;Open University Press,2003.
[19]Duckett,Jane.The Chinese State’s Retreat from Health;Policy and the Politics of Retrenchment,London;Routledge,2011.
[20]Engstroem,Timothy and Wade Robison(ed.),Health Care Reform;Ethics and Politics,University of Rochester Press,2006.
[21]Eriksen,Thomas Hylland.Small Places,Large Issues;An Introduction to Social and Cultural Anthropology.Pluto Press,2001.
[22]Espelt,Albert,Carme Borrell,Maica RodriguezSanz,Carles Muntaner,M Isabel Pasarín,Joan Benach,Maartje Schaap,Anton E Kunst,and Vicente Navarro,“Inequalities in health by social class dimensions in European countries of different political traditions”,International Journal of Epidemiology,2008;37(5),1095-105.
[23]Fukuyama,Francis,The End of History and the Last Man,New York;Avon Books,1992.
[24]Gupta,Vin,Vanessa B.Kerry,Eric Goosby,and Robert Yates.“Politics and Universal Health Coverage—The Post-2015 Global Health Agenda.”New England Journal of Medicine.2015:373,(13):1189-1192.
[25]Hann,Alison,Health Policy and Politics,Ashgate Publishing,2007.
[26]Harrison,Stephen,and Ruth Mc Donald.The Politics of Healthcare in Britain,Sage Publications Ltd,2008.
[27]Hunter,David,The Health Debate,The Policy Press,2008.
[28]Hunter DJ,Williams G.NHS“reform”in England:where is the public interest?BMJ 2012;344;e2014.
[29]Hunter,David,“Role of Politics in Understanding Complex,Messy Health Systems;An Essay,”BMJ,2015;350,h1214.
[30]Hunter DJ.Change of government;one more big bang health care reform in England’s National Health Service.Int J Health Serv 2011;41;159-74.
[31]Klein,Rudolf,The New Politics of the NHS;From Creation to Reinvention,Radcliffe Publishing,2006.
[32]Kornreich,Yoel,Ilan Vertinsky,and Pitman B.Potter,“Consultation and Deliberation in China;The Making of China's Health-Care Reform,”China Journal,2012:68,176-203.
[33]Lowi,Theodore J.American Business,Public Policy,Case Studies,and Political Theory.World Politics,1964,16(4).
[34]Lundberg,Olle,Commentary:politics and public health some conceptual considerations concerning welf are state characteristics and public health outcomes,International Journal of Epidemiology,2008:37 5),1105-8.
[35]Lundberg,Olle,“Politics and public health some conceptual considerations concerning welfare state characteristics and public health outcomes”,International Journal of Epidemiology,2010:39(3),632-4.
[36]Morone,James,“Introduction:Health Politics and Policy”,in Morone,Litman&Robins(eds.)Health Politics and Policy,2008,4th edition,1-22.
[37]Muntaner,Carles,Carme Borrell,Edwin Ng,Haejoo Chung,Albert Espelt,Maica Rodriguez-Sanz,Joan Benach and Patricia O’Campo,“Review article:Politics,welfare regimes,and population health:controversies and evidence,”Sociology of Health&Illness,2011:33(6),946-964.
[38]Navarro,Vicente(ed.),The Political and Social Contexts of Health.Baywood Publishing Company,Inc.,2004.
[39]Navarro,Vicente,Carles Muntaner,Carme Borrell,Joan Benach,Agueda Quiroga,Maica RodríguezSanz,Núria Vergés,M Isabel Pasarín,“Politics and Health Outcomes,”The Lancet,2006:368,1033-37.
[40]Pollock,Allyson,NHS plc:The Privatisation of Our Health Care,Verso Books,2005.
[41]Pollock,Allyson,“NHS Privatisation Keeps on Failing Patients Despite a Decade of Warnings”,the Guardian,2014,available at http://www.theguardian.com/commentisfree/2014/aug/15/nhs-privatisation-failing-patients-warnings.
[42]Purdy,Michael and David Banks(ed.),The Sociology and Politics of Health:A Reader,Routledge,2001.
[43]Roberts M,Hsiao William,Berman P,Reich M.Getting health reform right:a guide to improving performance and equity.Oxford:Oxford University Press,2008.
[44]Shaw,Mary,Danny Dorling,David Gordon,George Davey,The Widening Gap:Health Inequalities and Policy in Britain,The Policy Press,1999.
[45]Walt,Gill,and Patrick Vaughan.“Politics of health planning.”World Health Forum,vol.7,no.1,pp.44-9.1986.
[46]Walt,Gill,Health Policy:An Introduction to Process and Power,London:Zed Books,1994.
[47]Webster,Charles,The NHS:A Political History,Oxford:Oxford University Press,2002.
1如巴戈特(2012)提出研究开始转变到关注医疗卫生议题的出现、政策的形成及其贯彻实施背后的政治过程。
2 Marx&Engels在The German Ideology里表示意识形态是一系列源自物质条件的错误的观念,这些观念代表统治阶级的利益。Lenin在What Is To Be Done?里表示意识形态是阶级斗争中一个有用的武器,它可以被各方利用来促进他们的利益,而不论这些观念的真假。Gramsci在Selections from the Prison Notebooks 1929一书里表示意识形态是社会形成的有机和必要部分,意识形态可以把不同群体和不同观念结合到一起,从这个意义上说它是社会粘合剂。占霸权地位的意识形态往往把互相竞争的意识形态的部分结合到一起,因此把多个社会群体的利益也融合到一块。而Althusser在Lenin and Philosophy and other essays一书里指出意识形态是人类社会的基本的元素,是人类历史呼吸和生命的氛围。意识形态在各种社会形态中无所不在,它被用来把社会粘合到一起。(引自Bambra,Fox,and Scott-Samuel,2007)。
3 他们进一步指出:自由主义者认为国家的政治、经济、社会生活,应以维护个人自由为最终目的,国家的作用不是干涉或支配个人的生活,而是以法律为手段维护秩序;平等主义是基于所有个人要求在社会上的平等政治主张,以及所有人应平等地得到社会的保障,包括法律权利、政治权利、公民权利的平等。
4 如上议院David Owen发起的NHS2015年恢复法案运动(The Campaign for the NHS Reinstatement Bill2015),推动在2015年5月有足够的议员回到议会中,让无论哪个政党或政党联盟新组成的政府把医疗服务市场化从2012年健康与社会保健法案中剔除出去。2014年12 月,David Owen出版了新书《民族的健康;NHS在危机中》(The Health of the Nation;NHS in Peril),详述2012年健康与社会保健法案造成的破坏以及废除议案中最坏部分的原因,并提出计划如何可行地让NHS重新回归公益性。
5 广大公众和医务人员开始参与反对私有化NHS的运动,要求NHS的承包合同留在公共领域,反对关闭医院、取消服务和裁减人员,并游说议员,发起了“保留NHS公有”(KONP-Keep Our NHS Public)的运动参看运动官网http;//www.keepournhspublic.com/index.php。
6 罗布·巴戈特列举出英国NHS借鉴其他卫生保健系统的几项重要改革;国家医疗卫生服务信托基金会的创立受到来自西班牙、瑞典以及丹麦类似机构的启迪;委托服务的引入学习了采用市场导向路径卫生保健的国家(比如美国);用私营部门来补充国家卫生保健受到了采取多元方式运营医疗体系的欧洲大陆国家的影响(比如德国与荷兰)。