规制对孕产保健服务公平性影响的案例研究
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摘要
一、研究背景
健康公平是让所有社会成员均有机会达到尽可能高的健康水平,要实现这一目标,需要有良好的卫生服务系统,保证健康权作为人的一项基本权利,不受到经济水平、外部环境等的影响。2000年世界卫生组织将卫生服务公平性列为卫生系统绩效评价的重要指标,此后各国围绕健康和卫生服务公平性开展了广泛研究,来自妇幼保健服务领域的研究表明,经济发展水平所导致孕产保健服务利用不公平,是低收入、中等收入和高收入国家之间孕产妇死亡率形成巨大反差的原因之一。我国学者对孕产妇健康和服务利用公平性的研究虽有限,但结果均提示,我国城乡之间、东中西部地区之间孕产保健服务利用和孕产妇健康存有不公平,而城市流动人口与户籍人口在孕产保健服务利用和孕产妇死亡上所表现出来的明显差距,已成为城市孕产保健服务系统面临的挑战。
经济因素和卫生服务系统是影响我国卫生服务公平性的两个主要因素。社会经济发展引起贫富差距增加,影响健康的决定因素变得愈加不公平；而卫生服务改革的市场化倾向,以及政府在矫正市场失灵、改善卫生服务尤其是公共卫生服务公平性上的职能缺位,使得卫生服务公平性进一步下降。规制的源起之一,是希望达到公平、实现权力等社会目标,世界卫生组织明确提出：规制是政府和卫生系统的责任,是促进卫生服务公平性的重要工具,通过政府制定各种规则对卫生服务市场进行适度规制,规制相关参与者的行为以确保其履行职责,以强化卫生服务的公平性,保障人人享有健康这项人类的基本权利。因此,寻找改善我国孕产保健服务公平性的途径,将不可避免的涉及我国的卫生服务体系和卫生服务规制体系。在缩小孕产保健服务利用的公平性上,我国政府已采取了一系列的措施,近十年来全国住院分娩服务利用公平性的显著改善,揭示了有效的政府规制对促使改善公平的政策达到预期目标的重要作用。
目前,我国对卫生服务公平性的研究中,针对孕产保健服务公平性的研究相对较少,且尚未见到从政府规制的角度深入分析孕产保健服务规制对公平性影响的实证研究。本研究正是致力于填补这一空白,以促进孕产保健服务规制发挥更大的作用,推动孕产妇健康公平性的不断改善。
二、研究目的
本研究在描述与分析我国孕产保健服务的公平性现况的基础上,利用规制理论和规制效果评价框架,以上海某区紧急产科保健服务为实证案例,分析有效的政府规制如何影响健康公平性,探讨规制的要素对规制效果的影响,并以此为借鉴,在了解该区基本孕产保健服务利用公平性及其相关规制的基础上,以良好治理和有效政府规制为理论框架,提出进一步改善孕产保健公平性的政策建议。
三、研究内容与研究方法
1、以中国卫生统计年鉴为二次数据来源,采用公平性的评价理论和分析方法,分析2000-2009全国孕产妇健康公平性以及2005-2009全国孕产保健服务利用和资源配置的公平性,以期对我国孕产保健服务的公平性现况做出较为全面的描述,并通过分析全国住院分娩服务利用公平性显著提高的原因,初步探讨有效的政府规制对落实公平性政策、改善孕产保健服务利用公平性的作用。
2、采用定性研究的方法,以上海市某中心城区为研究现场,选择与上海市紧急产科保健服务相关的4类参与者共22人进行关键知情人半结构式访谈,结合使用文献分析法,评价紧急产科保健服务规制对改善上海市户籍和非户籍孕产妇健康公平性的影响,并分析规制的环境、过程、参与者和机制对紧急产科保健规制效果的影响。
3、采用该区2004-2011年妇幼卫生报表作为二次数据来源,分析户籍和非户籍孕产妇对基本孕产保健服务利用的公平性,并通过现场调查的方法在全区13个社区卫生服务中心对436名产后6个月内的妇女进行问卷调查,进一步分析2011年该区户籍和非户籍孕产妇对保健服务利用的公平性和影响因素,通过定性研究的关键知情人半结构式访谈,了解通过规制进一步改善孕产保健服务公平性的方向和关键环节,并以良好治理和有效规制为理论框架,提出进一步改善公平性的政策建议。
四、主要研究结果
1.2000-2009年的10年间,全国的MMR持续下降,并以西部地区下降趋势最显著,2003-2009年间,东部和中部地区的MMR分别下降了44%和52%,而西部地区的MMR下降了62%。以极差法衡量2000-2009年全国及不同地区孕产妇健康公平性,东部与中部地区的孕产妇死亡差距变化不大,10年间MMR的率差约维持在10-20/10万之间,虽然东部和西部地区的孕产妇死亡率差距最大,但这种差距缩小的趋势却最明显,由2003年的65.43/10万缩小至2009年的27.80/10万。以集中指数反应健康公平性,无论是省际还是地区间,2000-2009年的集中指数全为负值,表明孕产妇死亡集中于人均GDP较低的省份或地区；10年间,省际和地区间的集中指数均在-0.2～-0.3之间波动,与2000年相比,2009年的集中指数绝对值变化极小,提示10年里全国孕产妇的健康公平性未得到明显的改善。
2.2005-2009全国产前检查、住院分娩、产后访视和系统管理四类孕产保健服务的集中指数均大于零,表明服务利用存有不公平,按人均GDP衡量,经济水平越低的省市,孕产妇对保健服务利用越差。四类孕产保健服务中,系统管理的集中指数绝对值最大,表明公平性最低；产前检查的集中指数绝对值最小,公平性最好。2005-2009年,除住院分娩服务外,其他三类服务的集中指数变化很小,公平性未见明显改善,而住院分娩服务利用的集中指数由2005年的0.0593迅速下降至2009年的0.0177,表明公平性持续且明显改善,这离不开”降消”项目在这一地区所取得的成功,也表明了有力的政府规制对改善公平性的作用。
3.上海市孕产妇健康不公平,主要体现在流动和户籍孕产妇死亡的健康公平性上,10年间,非户籍孕产妇是全市孕产妇死亡的主流,加强危重孕产妇转诊、会诊抢救,是降低MMR尤其是非户籍孕产妇MMR的主要途径之一。围绕紧急产科保健上海市制定了一系列规制,并以2008年颁布的规制发挥了最为核心的作用,定性研究表明,该规制的出台和执行,有效提高了危重孕产妇抢救成功率并推动了全人群尤其是非户籍孕产妇MMR下降,达到了预期效果,孕产妇的健康不公平缩小,而规制的执行过程也很好的体现了服务提供的公平性。
4.规制产生效果的促成因素包括：规制的目标与内容契合国内外所倡导的母亲安全的政策环境；制定过程中以信息为基础的设计、自上而下行政和技术管理的密切结合、规制执行前必要恰当的解读；孕产妇死亡评审、问责制、考核、惩罚、激励等机制的综合运用,尤其是问责制对相关的参与者所形成的有效监督与约束；各级服务管理者和提供者作为规制主要参与者,其权利和能力保证了规制的有力执行和良好效果。研究同时也表明,规制效果及持续性的阻碍因素包括：财政部门这一关键参与者的缺位,紧急产科保健服务可持续受限；激励机制未能发挥更好的作用影响了执行层面参与者的积极性。
5.对紧急产科保健服务规制的研究所得的另一重要结果是,减少危重孕产妇的发生、进一步缩小健康不公平,仅对紧急产科保健服务进行规制还不够,必须关口前一,重点规制基本孕产保健尤其是产前保健。而目前上海市对基本孕产保健服务所进行的规制主要是2010年出台的围绕孕产妇全覆盖管理的规制,这一规制旨在发动社区支持组织的力量完善社区孕情监测网络,加强全人群尤其是非户籍孕产妇对孕早期建册和系统管理服务利用。
6.以率差和集中指数评价2004-2011年上海市某区户籍和非户籍对6类基本孕产保健服务利用的公平性,早孕建册、规范产检和系统管理三类服务利用不公平最为明显且2004-2009年有扩大趋势,但2010年该区全面推行全覆盖孕产保健服务管理后,早孕建册和系统管理服务利用公平性显著改善：早孕建册的集中指数由2004年的0.1308上升至2009年的0.1746后,于2010年下降0.1034,2011年继续降至0.0594；而系统管理的集中指数由2004年的0.1434逐步升至2009年的0.1804,于2010年开始迅速下降至0.1054,并于2011年继续下降至0.0652,这种明显改善部分反映了全覆盖规制的效果。
7.现场调查共纳入436名研究对象,其中户籍孕产妇238名,非户籍孕产妇168名。分析表明,该区户籍和非户籍孕产妇的学历、职业、家庭人均月收入、医疗保险和生育保险覆盖率具有显著性差异(P<0.05),且两类人群对早孕检查、规范产检、产后访视三类基本孕产保健服务利用存在明显差异；以率差衡量,最不公平的是早孕建册服务利用,户籍和非户籍孕产妇早孕建册服务利用的率差为29.4%,率比为1.44,集中指数为0.0816；对8次以上产检服务利用的率差为26.3%,率比为1.41,集中指数为0.1104；产后访视服务利用不公平性最小,率差为22.6%,率比为1.34,集中指数为0.0798。户籍和非户籍孕产妇对其他保健服务如产前筛查、孕妇学校和导乐分娩服务利用也存在明显不公平,并以孕妇学校最为明显,率比为1.6。影响户籍和非户籍孕产妇保健服务利用的主要因素是孕产妇的户籍、学历和生育保险。上海户籍、有生育保险的妇女,更有可能在孕早期建小卡并完成规范(整个孕期≥8次)的产前检查。除户籍因素外,学历水平越高的孕产妇,更有可能寻求和利用产后访视服务。
8.定性研究进一步提示,全覆盖规制对改善该区户籍和非户籍孕产妇在早孕建册和管理服务利用公平性发挥了明显作用,但关键参与者的缺位(财政部门、社区支持组织等)影响了规制的效果及可持续性。
五、基于良好治理和有效规制理论进一步改善上海市孕产保健公平性的政策建议
1、进一步改善我国及上海市孕产保健服务的公平性,应重点关注产前保健服务利用的公平性,以项目推动服务的改善并通过政府规制落实为常态,是可行的途径之一。
2、环境因素影响规制的效果。新医改推行的基本公共卫生均等化服务,是改善孕产保健服务公平性的契机,改善孕产保健服务公平性的规制,需要抓住这一良好的环境促成因素,以强化规制效果。
3、改善公平性的孕产保健服务规制,需要在良好治理的框架下,纳入更多参与者并实现以政府为主导的多元共治,推动规制持续发挥作用,对于全覆盖规制,财政和公民社会是两个重要的参与者,应当发挥更大作用。
(1)、财政部门是保障规制顺利执行和持续发挥效果的重要参与者,孕产保健服务的规制不论是设计、管理还是执行,都理应纳入该参与者。
(2)、发挥公民社会的重要力量,为孕产保健服务规制的可持续性提供支持和保障。
4、完善全覆盖孕产保健服务规制的内容,增加对孕妇学校、规范产检服务的规制内容,从多个环节推动上海市孕产保健服务利用的公平性。
5、改善全覆盖孕产保健服务规制的可持续性,需要加强规制制定过程的程序性和规范化,并通过对规制的解读增强规制的可行性和可操作性,以改善执行的效果。
6、发挥全覆盖规制改善基本孕产保健服务公平性的作用,需要综合运用激励、惩罚、考核等多种机制,保证相关参与者充分履行职责,在财政部门纳入规制过程的前提下,应更多的采用经济性激励机制以确保规制执行者更加主动积极的参与规制的过程,实现规制的目标。
1、Background
Equity of health means every member of society has the opportunity to achieve a good health state.to achieve this goal, a fine health care system is necessary to ensure the basic right of the citizens not be affected by their economic states or other external factors. Equity was recommended as a key indicator to evaluate the healthcare system by WOH in2000, since then the equity of health and health care service became a hot topic for researchers in all counties. Studies on maternal and child healthcare showed that the inequity of utilization of maternal healthcare service (MHS) which was caused by different economic level is one of the main factors of health inequity, reflected on the huge gaps on Maternal Mortality Ration (MMR) between low-income, middle-income and high-income countries. Limited studies in maternal healthcare (MH) in china also showed that inequity of maternal health and MHS exists between urban and rural area, and different regions; the gaps in utilization of MHS and maternal health between migrants and local residents in urban area has also became a big challenge of MHS system.
The two main factors of inequity of healthcare in china are economic factors and healthcare system. Development of society caused a wide gap on healthcare service utilization between rich and poor, the healthcare market cannot ensure the equity of utilization while the government did not play the key role in correcting the market failure. The origin of regulation is to achieve equity and other social goals. As recommended by WHO, regulation is an important tool in improving equity and government should take the responsibility in healthcare regulation. To find the way of improving MH equity, it is necessary to study on regulation. Chinese government had initiated a serious measure to improve the inequity of MHS utilization, the great improvement of hospital utilization on institutional delivery is a good example, which reflected the key role of regulation in improving equity.
Currently, studies on MH equity are limited, and there is no study focused on regulation and its impact on MH equity. This study intended to narrow these gaps to some extent, and serve for facilitating the development of regulation, as well as promoting the equity of maternal health care.
II Study goal
To analyze how an effective regulation play its role in improving health equity through a case study on Emergency Obstetric Care (EmOC) in a central district in Shanghai, and to explore how the key aspects of regulation affect its effect. Based on the EmOC regulation, to further analyses the equity of MHS utilization between local and migrant pregnant women in this district and find the gaps on regulations related to basic maternal healthcare, and to provide evidence-based recommendations for the further development of regulations and maternal healthcare equity.
Ⅲ Study contents and methodologies
1. Using the secondary data in China Health Statistical Yearbook to evaluate the equity of maternal health from2000to2009and the equity of MHS utilization and MHS resource allocation from2005-2009, and analysis the reasons on the improvement of institutional delivery equity.
2. The effect of EmOC regulation on health equity between local and migrant pregnant women was analyzed by qualitative research methods.22respondents divided by4types were selected and semi-structured in-depth interview were conducted. Combined with the literature analysis method, the context, process, actors and mechanisms of regulation were evaluated based on the regulation conceptual framework.
3. Using secondary data in the maternal health annual statistic report of this district to analyze the equity of MHS utilization between migrants and local residents. To analyze the factors that affect the utilization, a cross-sectional study was conducted. Totally436women from all13community health centers were investigated. Combined with the semi structured in-depth interview, the current gaps of regulation related to the basic MHS were analyzed and recommendations were proposed based on the principle of good governance and regulation.
IV Main findings
1.The national MMR kept on decreasing from2000to2009, and the most obvious trend of decline is MMR in the western region. From2003to2009, MMR in eastern and central region decreased by44%and53%, and MMR in western region decreased by62%. Ration Different (RD), Ratio Rate (RR) and Concentration Index (Cl) were calculated to evaluate the equity of maternal health. From2000to2009, the RD between eastern and central regions was10-20/100000, in contrast, the RD between eastern and western regions decreased obviously from65.43/100000to27.80/100000. The equity of maternal health was not improved from2000to2009if evaluated by Cl:all the values of Cl is negative, the Cl was-0.2～-0.3and compared with the Cl in2000, the absolute value of Cl in2009changed a little.
2. The value of Cl for the utilization of prenatal check up, institutional delivery, postpartum interview and systematic management were positive, which means inequity existed in different regions. In the four types of services, the absolute value of Cl for systematic management was the highest, which means utilization of this service was the most inequitable. The absolute value of Cl for prenatal check-up was the lowest. From2005to2009, except for institutional delivery, the Cl of the other three kinds of service changed a little. However, the Cl of institutional delivery utilization decreased rapidly from0.0593to0.0177, which means a great improvement of equity in the utilization of institutional delivery, this is also a reflection of the effectiveness of regulations targeted on improving utilization of this service in western region.
3. The inequity of maternal health was reflected on migrants and local pregnant women. In the recent decade, most of the maternal deaths in Shanghai were migrant women, therefore, reconstruct the EmOC network in Shanghai and improve the consultation and rescue of critically ill pregnant women (CIPW) is one of the solutions to reduce MMR especially MMR of migrants. Since2007, a serious of regulations were issued by Shanghai bureau of health (BOH), and the regulation issued in April2008was the key one, which played an important role in improving the equitable access to EmOC service in Shanghai. The qualitative study showed that this regulation greatly improved the quality of EmOC, with the great increase of successful rescue rate of CIPW, the MMR of migrants decreased obviously and inequity of maternal health between migrants and local women improved.
4. The enabling factors of the regulation effect are as follows:the international and national context for safe motherhood; the evidence-based process of regulation design and the interpretation of regulation at district and hospital levels. The application of different regulation mechanisms especially Accountability mechanism, which play the key role in supervising related actors; the actors involved in regulation process were mainly heath administrators and providers, which means the regulation can be well administrated and implemented at each level.Themain barriers of regulation effect and its sustainability are the financial sectors, which are the key actors of regulation, were not involved in the whole process of regulation, and the incentive mechanism did not play a better role in regulation.
5.The study on EmOC regulation also showed that it is not enough to reduce the MMR of migrants only relaying on regulating EmOC service, another key point of regulation should be the basic MHS especially prenatal care. Currently, the main regulation focus on basic MHS is the regulation issued in2010by shanghais BOH, which is another output of EmOC regulation. this regulation is specifically focused on improving the utilization of establishing maternal card and systematic management.
6. The utilization of establishing maternal card, and systematic management were inequity obviously and gradually expanded from2004to2009in this central district. However, this trend reversed since2010in which year the2010regulation was implemented in this district, the Cl of establishing maternal card kept on increasing from0.1308in2004to0.1746in2009, then decreased to0.1034in2010, in2011, the value is0.0594. The Cl of systematic management kept on increasing from2004to2009, then decreased since2010, the value is0.1434in2004and0.1804in2009, in2011, the value is only0.0652. The improvement of inequity of these two services reflected the effect of2010regulation.
7.436cases included238local women and168migrants were involved in the cross sectional study conducted in this central district. The education level, occupation, average income per person in family and the coverage of health insurance as well as reproductive insurance were significantly different between these two groups of women (P<0.05). The utilization of establishing maternal card, prenatal check-up (more than8times), and the postpartum interview were lower in migrants then in local women with a significant differences. For the establishing maternal care, the RD is29.4%, RR is1.44and Cl is0.0816. for the prenatal check-up(more than8times), the RD is26.3%, RR is1.34and Cl is0.0798. The utilization of other MHS such as prenatal screening, school for pregnant women. The main factors that affect the utilization of MHS are the place where the woman is registered, the education and the reproductive insurance, the local pregnant women and women with reproductive insurance are more likely to establish maternal card and do prenatal check-up no less than8times.
8. The qualitative analysis on the2010regulation showed that the regulation played an important role in improving the utilization of establishing maternal card and systematic management. However, the sustainability of this regulation was affected by some factors, especially the key actors and their role.
V Recommendation for further improving equity of maternal health
1. To further improve the equity of MHS, the prenatal care should be the next focus point, and a possible way is improve the utilization of service by project then normalizing the service by regulations.
2. Context is important to the regulation effect. The new healthcare reform focused on the equalization of public health services is an enabling factor for improving equity of maternal health and MHS, actors of the2010regulation should take the opportunity
3. More actors should be involved in the2010regulation to ensure the sustainability of regulation.
(1) Financial sectors should be involved in the process of regulation especially the stage of regulation formulation.
(2) Civil society should play a greater role in the management of migrant pregnant women to ensure the sustainability of regulation.
4. Requirements on other MHS such as school of pregnant women should be involved into the content of2010regulation to further improve the equity of service utilization.5. The process of regulation formulation should be procedural and normalize. To make sure the good effect of regulation, interpretation is necessary and need at each district.
6. Mechanisms such as incentive, sanction and performance assessment should be used synthetically, especially the economic incentive mechanism, which can ensure the active participation of implementers.
健康公平是让所有社会成员均有机会达到尽可能高的健康水平,要实现这一目标,需要有良好的卫生服务系统,保证健康权作为人的一项基本权利,不受到经济水平、外部环境等的影响。2000年世界卫生组织将卫生服务公平性列为卫生系统绩效评价的重要指标,此后各国围绕健康和卫生服务公平性开展了广泛研究,来自妇幼保健服务领域的研究表明,经济发展水平所导致孕产保健服务利用不公平,是低收入、中等收入和高收入国家之间孕产妇死亡率形成巨大反差的原因之一。我国学者对孕产妇健康和服务利用公平性的研究虽有限,但结果均提示,我国城乡之间、东中西部地区之间孕产保健服务利用和孕产妇健康存有不公平,而城市流动人口与户籍人口在孕产保健服务利用和孕产妇死亡上所表现出来的明显差距,已成为城市孕产保健服务系统面临的挑战。
经济因素和卫生服务系统是影响我国卫生服务公平性的两个主要因素。社会经济发展引起贫富差距增加,影响健康的决定因素变得愈加不公平；而卫生服务改革的市场化倾向,以及政府在矫正市场失灵、改善卫生服务尤其是公共卫生服务公平性上的职能缺位,使得卫生服务公平性进一步下降。规制的源起之一,是希望达到公平、实现权力等社会目标,世界卫生组织明确提出：规制是政府和卫生系统的责任,是促进卫生服务公平性的重要工具,通过政府制定各种规则对卫生服务市场进行适度规制,规制相关参与者的行为以确保其履行职责,以强化卫生服务的公平性,保障人人享有健康这项人类的基本权利。因此,寻找改善我国孕产保健服务公平性的途径,将不可避免的涉及我国的卫生服务体系和卫生服务规制体系。在缩小孕产保健服务利用的公平性上,我国政府已采取了一系列的措施,近十年来全国住院分娩服务利用公平性的显著改善,揭示了有效的政府规制对促使改善公平的政策达到预期目标的重要作用。
目前,我国对卫生服务公平性的研究中,针对孕产保健服务公平性的研究相对较少,且尚未见到从政府规制的角度深入分析孕产保健服务规制对公平性影响的实证研究。本研究正是致力于填补这一空白,以促进孕产保健服务规制发挥更大的作用,推动孕产妇健康公平性的不断改善。
二、研究目的
本研究在描述与分析我国孕产保健服务的公平性现况的基础上,利用规制理论和规制效果评价框架,以上海某区紧急产科保健服务为实证案例,分析有效的政府规制如何影响健康公平性,探讨规制的要素对规制效果的影响,并以此为借鉴,在了解该区基本孕产保健服务利用公平性及其相关规制的基础上,以良好治理和有效政府规制为理论框架,提出进一步改善孕产保健公平性的政策建议。
三、研究内容与研究方法
1、以中国卫生统计年鉴为二次数据来源,采用公平性的评价理论和分析方法,分析2000-2009全国孕产妇健康公平性以及2005-2009全国孕产保健服务利用和资源配置的公平性,以期对我国孕产保健服务的公平性现况做出较为全面的描述,并通过分析全国住院分娩服务利用公平性显著提高的原因,初步探讨有效的政府规制对落实公平性政策、改善孕产保健服务利用公平性的作用。
2、采用定性研究的方法,以上海市某中心城区为研究现场,选择与上海市紧急产科保健服务相关的4类参与者共22人进行关键知情人半结构式访谈,结合使用文献分析法,评价紧急产科保健服务规制对改善上海市户籍和非户籍孕产妇健康公平性的影响,并分析规制的环境、过程、参与者和机制对紧急产科保健规制效果的影响。
3、采用该区2004-2011年妇幼卫生报表作为二次数据来源,分析户籍和非户籍孕产妇对基本孕产保健服务利用的公平性,并通过现场调查的方法在全区13个社区卫生服务中心对436名产后6个月内的妇女进行问卷调查,进一步分析2011年该区户籍和非户籍孕产妇对保健服务利用的公平性和影响因素,通过定性研究的关键知情人半结构式访谈,了解通过规制进一步改善孕产保健服务公平性的方向和关键环节,并以良好治理和有效规制为理论框架,提出进一步改善公平性的政策建议。
四、主要研究结果
1.2000-2009年的10年间,全国的MMR持续下降,并以西部地区下降趋势最显著,2003-2009年间,东部和中部地区的MMR分别下降了44%和52%,而西部地区的MMR下降了62%。以极差法衡量2000-2009年全国及不同地区孕产妇健康公平性,东部与中部地区的孕产妇死亡差距变化不大,10年间MMR的率差约维持在10-20/10万之间,虽然东部和西部地区的孕产妇死亡率差距最大,但这种差距缩小的趋势却最明显,由2003年的65.43/10万缩小至2009年的27.80/10万。以集中指数反应健康公平性,无论是省际还是地区间,2000-2009年的集中指数全为负值,表明孕产妇死亡集中于人均GDP较低的省份或地区；10年间,省际和地区间的集中指数均在-0.2～-0.3之间波动,与2000年相比,2009年的集中指数绝对值变化极小,提示10年里全国孕产妇的健康公平性未得到明显的改善。
2.2005-2009全国产前检查、住院分娩、产后访视和系统管理四类孕产保健服务的集中指数均大于零,表明服务利用存有不公平,按人均GDP衡量,经济水平越低的省市,孕产妇对保健服务利用越差。四类孕产保健服务中,系统管理的集中指数绝对值最大,表明公平性最低；产前检查的集中指数绝对值最小,公平性最好。2005-2009年,除住院分娩服务外,其他三类服务的集中指数变化很小,公平性未见明显改善,而住院分娩服务利用的集中指数由2005年的0.0593迅速下降至2009年的0.0177,表明公平性持续且明显改善,这离不开”降消”项目在这一地区所取得的成功,也表明了有力的政府规制对改善公平性的作用。
3.上海市孕产妇健康不公平,主要体现在流动和户籍孕产妇死亡的健康公平性上,10年间,非户籍孕产妇是全市孕产妇死亡的主流,加强危重孕产妇转诊、会诊抢救,是降低MMR尤其是非户籍孕产妇MMR的主要途径之一。围绕紧急产科保健上海市制定了一系列规制,并以2008年颁布的规制发挥了最为核心的作用,定性研究表明,该规制的出台和执行,有效提高了危重孕产妇抢救成功率并推动了全人群尤其是非户籍孕产妇MMR下降,达到了预期效果,孕产妇的健康不公平缩小,而规制的执行过程也很好的体现了服务提供的公平性。
4.规制产生效果的促成因素包括：规制的目标与内容契合国内外所倡导的母亲安全的政策环境；制定过程中以信息为基础的设计、自上而下行政和技术管理的密切结合、规制执行前必要恰当的解读；孕产妇死亡评审、问责制、考核、惩罚、激励等机制的综合运用,尤其是问责制对相关的参与者所形成的有效监督与约束；各级服务管理者和提供者作为规制主要参与者,其权利和能力保证了规制的有力执行和良好效果。研究同时也表明,规制效果及持续性的阻碍因素包括：财政部门这一关键参与者的缺位,紧急产科保健服务可持续受限；激励机制未能发挥更好的作用影响了执行层面参与者的积极性。
5.对紧急产科保健服务规制的研究所得的另一重要结果是,减少危重孕产妇的发生、进一步缩小健康不公平,仅对紧急产科保健服务进行规制还不够,必须关口前一,重点规制基本孕产保健尤其是产前保健。而目前上海市对基本孕产保健服务所进行的规制主要是2010年出台的围绕孕产妇全覆盖管理的规制,这一规制旨在发动社区支持组织的力量完善社区孕情监测网络,加强全人群尤其是非户籍孕产妇对孕早期建册和系统管理服务利用。
6.以率差和集中指数评价2004-2011年上海市某区户籍和非户籍对6类基本孕产保健服务利用的公平性,早孕建册、规范产检和系统管理三类服务利用不公平最为明显且2004-2009年有扩大趋势,但2010年该区全面推行全覆盖孕产保健服务管理后,早孕建册和系统管理服务利用公平性显著改善：早孕建册的集中指数由2004年的0.1308上升至2009年的0.1746后,于2010年下降0.1034,2011年继续降至0.0594；而系统管理的集中指数由2004年的0.1434逐步升至2009年的0.1804,于2010年开始迅速下降至0.1054,并于2011年继续下降至0.0652,这种明显改善部分反映了全覆盖规制的效果。
7.现场调查共纳入436名研究对象,其中户籍孕产妇238名,非户籍孕产妇168名。分析表明,该区户籍和非户籍孕产妇的学历、职业、家庭人均月收入、医疗保险和生育保险覆盖率具有显著性差异(P<0.05),且两类人群对早孕检查、规范产检、产后访视三类基本孕产保健服务利用存在明显差异；以率差衡量,最不公平的是早孕建册服务利用,户籍和非户籍孕产妇早孕建册服务利用的率差为29.4%,率比为1.44,集中指数为0.0816；对8次以上产检服务利用的率差为26.3%,率比为1.41,集中指数为0.1104；产后访视服务利用不公平性最小,率差为22.6%,率比为1.34,集中指数为0.0798。户籍和非户籍孕产妇对其他保健服务如产前筛查、孕妇学校和导乐分娩服务利用也存在明显不公平,并以孕妇学校最为明显,率比为1.6。影响户籍和非户籍孕产妇保健服务利用的主要因素是孕产妇的户籍、学历和生育保险。上海户籍、有生育保险的妇女,更有可能在孕早期建小卡并完成规范(整个孕期≥8次)的产前检查。除户籍因素外,学历水平越高的孕产妇,更有可能寻求和利用产后访视服务。
8.定性研究进一步提示,全覆盖规制对改善该区户籍和非户籍孕产妇在早孕建册和管理服务利用公平性发挥了明显作用,但关键参与者的缺位(财政部门、社区支持组织等)影响了规制的效果及可持续性。
五、基于良好治理和有效规制理论进一步改善上海市孕产保健公平性的政策建议
1、进一步改善我国及上海市孕产保健服务的公平性,应重点关注产前保健服务利用的公平性,以项目推动服务的改善并通过政府规制落实为常态,是可行的途径之一。
2、环境因素影响规制的效果。新医改推行的基本公共卫生均等化服务,是改善孕产保健服务公平性的契机,改善孕产保健服务公平性的规制,需要抓住这一良好的环境促成因素,以强化规制效果。
3、改善公平性的孕产保健服务规制,需要在良好治理的框架下,纳入更多参与者并实现以政府为主导的多元共治,推动规制持续发挥作用,对于全覆盖规制,财政和公民社会是两个重要的参与者,应当发挥更大作用。
(1)、财政部门是保障规制顺利执行和持续发挥效果的重要参与者,孕产保健服务的规制不论是设计、管理还是执行,都理应纳入该参与者。
(2)、发挥公民社会的重要力量,为孕产保健服务规制的可持续性提供支持和保障。
4、完善全覆盖孕产保健服务规制的内容,增加对孕妇学校、规范产检服务的规制内容,从多个环节推动上海市孕产保健服务利用的公平性。
5、改善全覆盖孕产保健服务规制的可持续性,需要加强规制制定过程的程序性和规范化,并通过对规制的解读增强规制的可行性和可操作性,以改善执行的效果。
6、发挥全覆盖规制改善基本孕产保健服务公平性的作用,需要综合运用激励、惩罚、考核等多种机制,保证相关参与者充分履行职责,在财政部门纳入规制过程的前提下,应更多的采用经济性激励机制以确保规制执行者更加主动积极的参与规制的过程,实现规制的目标。
1、Background
Equity of health means every member of society has the opportunity to achieve a good health state.to achieve this goal, a fine health care system is necessary to ensure the basic right of the citizens not be affected by their economic states or other external factors. Equity was recommended as a key indicator to evaluate the healthcare system by WOH in2000, since then the equity of health and health care service became a hot topic for researchers in all counties. Studies on maternal and child healthcare showed that the inequity of utilization of maternal healthcare service (MHS) which was caused by different economic level is one of the main factors of health inequity, reflected on the huge gaps on Maternal Mortality Ration (MMR) between low-income, middle-income and high-income countries. Limited studies in maternal healthcare (MH) in china also showed that inequity of maternal health and MHS exists between urban and rural area, and different regions; the gaps in utilization of MHS and maternal health between migrants and local residents in urban area has also became a big challenge of MHS system.
The two main factors of inequity of healthcare in china are economic factors and healthcare system. Development of society caused a wide gap on healthcare service utilization between rich and poor, the healthcare market cannot ensure the equity of utilization while the government did not play the key role in correcting the market failure. The origin of regulation is to achieve equity and other social goals. As recommended by WHO, regulation is an important tool in improving equity and government should take the responsibility in healthcare regulation. To find the way of improving MH equity, it is necessary to study on regulation. Chinese government had initiated a serious measure to improve the inequity of MHS utilization, the great improvement of hospital utilization on institutional delivery is a good example, which reflected the key role of regulation in improving equity.
Currently, studies on MH equity are limited, and there is no study focused on regulation and its impact on MH equity. This study intended to narrow these gaps to some extent, and serve for facilitating the development of regulation, as well as promoting the equity of maternal health care.
II Study goal
To analyze how an effective regulation play its role in improving health equity through a case study on Emergency Obstetric Care (EmOC) in a central district in Shanghai, and to explore how the key aspects of regulation affect its effect. Based on the EmOC regulation, to further analyses the equity of MHS utilization between local and migrant pregnant women in this district and find the gaps on regulations related to basic maternal healthcare, and to provide evidence-based recommendations for the further development of regulations and maternal healthcare equity.
Ⅲ Study contents and methodologies
1. Using the secondary data in China Health Statistical Yearbook to evaluate the equity of maternal health from2000to2009and the equity of MHS utilization and MHS resource allocation from2005-2009, and analysis the reasons on the improvement of institutional delivery equity.
2. The effect of EmOC regulation on health equity between local and migrant pregnant women was analyzed by qualitative research methods.22respondents divided by4types were selected and semi-structured in-depth interview were conducted. Combined with the literature analysis method, the context, process, actors and mechanisms of regulation were evaluated based on the regulation conceptual framework.
3. Using secondary data in the maternal health annual statistic report of this district to analyze the equity of MHS utilization between migrants and local residents. To analyze the factors that affect the utilization, a cross-sectional study was conducted. Totally436women from all13community health centers were investigated. Combined with the semi structured in-depth interview, the current gaps of regulation related to the basic MHS were analyzed and recommendations were proposed based on the principle of good governance and regulation.
IV Main findings
1.The national MMR kept on decreasing from2000to2009, and the most obvious trend of decline is MMR in the western region. From2003to2009, MMR in eastern and central region decreased by44%and53%, and MMR in western region decreased by62%. Ration Different (RD), Ratio Rate (RR) and Concentration Index (Cl) were calculated to evaluate the equity of maternal health. From2000to2009, the RD between eastern and central regions was10-20/100000, in contrast, the RD between eastern and western regions decreased obviously from65.43/100000to27.80/100000. The equity of maternal health was not improved from2000to2009if evaluated by Cl:all the values of Cl is negative, the Cl was-0.2～-0.3and compared with the Cl in2000, the absolute value of Cl in2009changed a little.
2. The value of Cl for the utilization of prenatal check up, institutional delivery, postpartum interview and systematic management were positive, which means inequity existed in different regions. In the four types of services, the absolute value of Cl for systematic management was the highest, which means utilization of this service was the most inequitable. The absolute value of Cl for prenatal check-up was the lowest. From2005to2009, except for institutional delivery, the Cl of the other three kinds of service changed a little. However, the Cl of institutional delivery utilization decreased rapidly from0.0593to0.0177, which means a great improvement of equity in the utilization of institutional delivery, this is also a reflection of the effectiveness of regulations targeted on improving utilization of this service in western region.
3. The inequity of maternal health was reflected on migrants and local pregnant women. In the recent decade, most of the maternal deaths in Shanghai were migrant women, therefore, reconstruct the EmOC network in Shanghai and improve the consultation and rescue of critically ill pregnant women (CIPW) is one of the solutions to reduce MMR especially MMR of migrants. Since2007, a serious of regulations were issued by Shanghai bureau of health (BOH), and the regulation issued in April2008was the key one, which played an important role in improving the equitable access to EmOC service in Shanghai. The qualitative study showed that this regulation greatly improved the quality of EmOC, with the great increase of successful rescue rate of CIPW, the MMR of migrants decreased obviously and inequity of maternal health between migrants and local women improved.
4. The enabling factors of the regulation effect are as follows:the international and national context for safe motherhood; the evidence-based process of regulation design and the interpretation of regulation at district and hospital levels. The application of different regulation mechanisms especially Accountability mechanism, which play the key role in supervising related actors; the actors involved in regulation process were mainly heath administrators and providers, which means the regulation can be well administrated and implemented at each level.Themain barriers of regulation effect and its sustainability are the financial sectors, which are the key actors of regulation, were not involved in the whole process of regulation, and the incentive mechanism did not play a better role in regulation.
5.The study on EmOC regulation also showed that it is not enough to reduce the MMR of migrants only relaying on regulating EmOC service, another key point of regulation should be the basic MHS especially prenatal care. Currently, the main regulation focus on basic MHS is the regulation issued in2010by shanghais BOH, which is another output of EmOC regulation. this regulation is specifically focused on improving the utilization of establishing maternal card and systematic management.
6. The utilization of establishing maternal card, and systematic management were inequity obviously and gradually expanded from2004to2009in this central district. However, this trend reversed since2010in which year the2010regulation was implemented in this district, the Cl of establishing maternal card kept on increasing from0.1308in2004to0.1746in2009, then decreased to0.1034in2010, in2011, the value is0.0594. The Cl of systematic management kept on increasing from2004to2009, then decreased since2010, the value is0.1434in2004and0.1804in2009, in2011, the value is only0.0652. The improvement of inequity of these two services reflected the effect of2010regulation.
7.436cases included238local women and168migrants were involved in the cross sectional study conducted in this central district. The education level, occupation, average income per person in family and the coverage of health insurance as well as reproductive insurance were significantly different between these two groups of women (P<0.05). The utilization of establishing maternal card, prenatal check-up (more than8times), and the postpartum interview were lower in migrants then in local women with a significant differences. For the establishing maternal care, the RD is29.4%, RR is1.44and Cl is0.0816. for the prenatal check-up(more than8times), the RD is26.3%, RR is1.34and Cl is0.0798. The utilization of other MHS such as prenatal screening, school for pregnant women. The main factors that affect the utilization of MHS are the place where the woman is registered, the education and the reproductive insurance, the local pregnant women and women with reproductive insurance are more likely to establish maternal card and do prenatal check-up no less than8times.
8. The qualitative analysis on the2010regulation showed that the regulation played an important role in improving the utilization of establishing maternal card and systematic management. However, the sustainability of this regulation was affected by some factors, especially the key actors and their role.
V Recommendation for further improving equity of maternal health
1. To further improve the equity of MHS, the prenatal care should be the next focus point, and a possible way is improve the utilization of service by project then normalizing the service by regulations.
2. Context is important to the regulation effect. The new healthcare reform focused on the equalization of public health services is an enabling factor for improving equity of maternal health and MHS, actors of the2010regulation should take the opportunity
3. More actors should be involved in the2010regulation to ensure the sustainability of regulation.
(1) Financial sectors should be involved in the process of regulation especially the stage of regulation formulation.
(2) Civil society should play a greater role in the management of migrant pregnant women to ensure the sustainability of regulation.
4. Requirements on other MHS such as school of pregnant women should be involved into the content of2010regulation to further improve the equity of service utilization.5. The process of regulation formulation should be procedural and normalize. To make sure the good effect of regulation, interpretation is necessary and need at each district.
6. Mechanisms such as incentive, sanction and performance assessment should be used synthetically, especially the economic incentive mechanism, which can ensure the active participation of implementers.
引文
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