我国农村公共卫生政府补偿政策研究
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摘要
我国是一个城乡二元经济结构的社会,农村居民生活、工作的环境与城市居民有着截然不同的差异,长期以来政府对农村补偿建立了一套独立的政策体系,也包括对公共卫生和基本医疗的补偿。
一、研究目的与背景
在对农村公共卫生补偿政策进行回顾的过程中,存在一些疑惑,如政府对农村的公共卫生到底应该采取怎样的态度?政府补偿的理论基础是什么?如果政府补偿立足于社会责任与道义,那么将有限的财政资源用于建立大病医疗保障与救助是无可争议的;但如果政府补偿立足健康投资理论,目的是为了提高劳动生产力,那么应该建立怎样的农村健康保障制度才是积极有效的呢?政府补偿的标准与原则应怎么选择?另外,政府应该采取怎样的补偿方式,是按照传统方式通过对医疗服务提供方进行补偿降低农民的疾病负担,还是通过建立新型农村合作医疗和救助对农民采取直接的医疗价格补偿?政府对农村公共卫生的补偿未来走向应该怎样选择?政府所做的事情到底在多大程度能够改变农村居民的健康状况?这些问题让我决定对农村公共卫生的政府补偿政策进行深入研究。
我们首先要做的工作就是进行大量的文献整理与分析,目的是了解农村公共卫生补偿主体、补偿标准和补偿对象的变化;结合社会发展了解这些变化的必然性及对补偿政策发展带来的影响。并在此基础上进行理论分析,帮助我们了解为什么对农村公共卫生进行补偿,应该补偿多少;帮助我们选择农村公共卫生政府补偿的理念与科学原则;帮助我们理解政府补偿的目标
其次,从政府的角度,通过对政策执行者们访谈了解目前不同地区农村公共卫生政府补偿政策执行的障碍;通过现场观察、文献和典型案例调查了解政策执行过程中在政府各部门、农村公共卫生供方、需方中存在的障碍。
最后针对补偿政策的主要障碍,如公共卫生补偿与公共财政体制融合;供方补偿标准与方式的选择;需方补偿原则和方案的选择等问题通过讨论获得提示和可选的解决方案
本课题研究的重要意义在于通过对政府补偿框架的界定,补偿方式的选择、医疗保障制度的发展等内容的探索来指导未来农村公共卫生政府政策的选择。
现阶段,卫生保健成本的增加是我国卫生系统面临的严峻挑战之一,居民收入的增长速度远远低于卫生服务保健花费的增长速度。与1990年相比,1999年城市与农村个人收入分别增长了288%与222%。而同期的门诊服务费用增长却达到625%。根据国家统计局的数据,1985年平均每个农村家庭花费家庭总收入的1.92%用于健康保健,到1999年,这一比例提高到了3.16%,而且越贫困的家庭该比例就表现得越高。依靠消费者自付的方式来补偿卫生服务提供,变得越来越来困难,结果必然导致自我医疗比例增加、卫生服务利用率,可及性降低、健康公平性受到威胁、健康需要得不到满足等一系列问题。
从三次卫生服务总调查结果来看,有健康保障的人口比例从1993年的30.2%降到1998年的23.6%。这一问题在农村地区表现更为明显,在1993年,农村居民的健康保险覆盖率已经低至12.8%,到1998年仅9.5%的居民享有健康保障。大部分居民必须为他们所需要的所有卫生服务支付大部分费用。
这一系列的数据均说明,长期以来我国的卫生补偿政策确实存在一些问题,例如,补偿框架的结构的不完善;政府补偿职责不清;补偿标准缺乏依据;对贫困人群的卫生补偿不够重视等。由于卫生补偿政策是卫生改革进程中关键环节之一,用于对卫生改革做出评价的标准,如卫生服务可及性、公平与效率、服务质量、贫困缓解等因素都不同程度受到卫生补偿政策执行效果的影响。合理有效的卫生补偿会给成功的卫生改革做出巨大的贡献。
本文主要通过回顾建国以来农村卫生补偿的政策框架、理论分析政府对农村卫生补偿的原因,其中包括经济学、政治学和伦理学等多因素的影响和应该补偿的理论额度、结合文献综述,现状调查和访谈的结果,就各级政府之间的补偿关系、供方补偿的形式、需方补偿的发展趋势等问题展开深入讨论,并提出相应的政策建议。
二、方法
资料搜集方法:文献复习通过查询中华人民共和国卫生部、民政部、发展改革委员会网站,世界银行,世界卫生组织等网站了解国际经验与国内相关政策进展,通过对万方、CNKI等中外数据库的文献查询了解与主题相关的研究进展;关键人员的访谈;现场数据搜集。
资料分析方法:分类资料的统计描述与分析;经济学的概念与理论,通过对公共卫生投资,公共卫生成本测算和公共产品供求关系等方面的理论分析,来帮助解释政府补偿的重要意义,政府补偿的标准、方式选择的技术基础和政府补偿的理论额度等专题;政治学利益集团分析方法;价值分析方法等。
质量控制:在设计和准备阶段通过专家论证和预调查以保证调查方案的科学性和可行性;选择有代表性的研究对象;保证所选用的二手资料可靠性强,大多来自国家政府部门发布的统计年鉴、政策法规和中国卫生总费用研究报告。
三、结果
通过对历史文献的归纳与整理,绘制出我国不同历史时期的政府公共卫生补偿框架,并对其进行政治和伦理学分析;从卫生补偿政策的历史发展过程,总结归纳政策的发展趋势和方向:政府目标逐渐具体和明晰;各级政府职责逐渐清晰,以财政分权为基础财政政策框架成为政府卫生补偿政策的基础;农村集体经济对卫生的补偿在2002年的决定中已经彻底消失了,转变为各级政府对农村卫生事业的投入;在需方补偿政策上,政府投入将作为一个支撑点,明确了将合作医疗和医疗救助相结合的具体方式;在卫生机构财务管理政策方面,逐渐体现将税收和价格作为政策调控的重要手段;对卫生服务提供者的补偿方式逐渐由以能力为基础的财政补偿转变为探索多种形式的财政补偿等。
但是我们也看到,长期以来的公共卫生的政府补偿政策存在明显的,难以克服的缺陷,就是目的不明确,补偿原则模糊不清。
运用农业经济学、公共产品、公共卫生、卫生投资、公平与效率等多学科理论对政府对公共卫生,特别是对农村的公共卫生进行补偿的重要意义、补偿目标、理论范围、挑战和评价标准进行了全方位的论述。
通过对政府卫生补偿政策现状研究,了解目前农村公共卫生补偿政策的障碍与挑战。通过对不同地区东、中、西部资料的收集和关键人员的深入访谈,了解到现阶段政府对卫生补偿所考虑的主要因素、不同的特征和存在的问题。从调查结论来看,我国政府的卫生补偿仍然普遍存在技术效率和分配效率低下等问题,但不同地区问题的侧重点却有所不同。
四、讨论
针对我国公共卫生补偿政府职责不清,东、中、西部政府补偿不平衡等问题进行讨论,明确中央与地方政府的职责分工、改善转移支付方式与财政补偿制度。为了进一步明确各级政府职责,尝试把不同的公共卫生产品分为全球性公共卫生产品、全国性公共卫生产品、区域性公共卫生产品和地方性公共卫生产品。中央政府可以通过专项财政转移支付等方式对困难地区的区域性和地方性公共卫生产品进行适当的补偿。
针对供方补偿存在问题进行讨论很多经验证据表明,如果补偿合理,营利机构也能像公立机构一样提供预防保健服务;如果政府补偿存在问题,公立机构一样也会存在滥用药品和提供不必要的医疗服务等现象。由于我国存在多种提供者所有制形式,因此,针对不同的所有制形式,本文提出了不同的政府补偿方式,例如,对卫生提供机构采取以需求为基础的预算补偿方式;对私人所有的营利性机构采取政府购买的补偿方式等。由于受到政治因素的影响,如部门间政治利益等关系的影响,卫生服务提供机构所有权问题依然是社会争论的一个焦点,针对政府所有的提供机构采取收支两条线的补偿方式又被重新提出来。但是对于政府购买和收支两条线这两种政府补偿方式来说,由于受到社会条件、经济条件、技术条件等多方面的影响,目前并不适合广泛的推广和实施。
针对需方补偿存在的问题进行讨论通过对我国医疗保障制度结构分析、新型农村合作医疗制度建立的政治背景和制度基础,制度建设进展等方面的描述与解释,认为在新型合作医疗方案完善的过程中门诊服务应该是政府补偿不可缺少的内容;在有条件的地方,选择按比例递减的补偿方式;按健康需求设计合理补偿水平等。通过城乡需方医疗保障方式的比较和国际医疗保障计划的描述,探索未来农村需方补偿方式的发展方向。对于贫困医疗救助而言其探索的方向应该是扩大受益范围,重视临界贫困状态;克服部门利益局限性坚持以医疗保障制度为平台实施医疗救助;根据实际需求与财政能力相结合制定救助方案;明确界定贫困人群中最困难的人员和最急需的医疗支出。农村医疗救助政策原则应该得到修改和进一步完善。
作为一个政策研究的结论,在现有的框架下,我们尽力在补偿功能、机制、产出等方面去探索未来政策发展的方向。首先,政府作为公共卫生补偿的主体,补偿政策的发展受到主体间关系变化的影响。随着公共财政体制的建立,中央与地方政府之间的关系必然发生一些显著的变化。公共卫生补偿职责的进一步明确与收支平衡的调整是未来补偿政策必然的发展方向;其次,从补偿的成本效果上来看,由于政府对农村公共卫生补偿的主要目的还是期望能够在于改善广大农民的健康状态,减少城乡差异,提高初级卫生保健的覆盖面等,这些指标近几年来每年都有一定的改善,但与政府补偿的投入是否成正比,未来的政府补偿政策发展方向必然通过针对影响人们的生活的主要因素,调整政府财政补偿的基本方向与结构,让政府投入能够更有效的改变人们的生活;第三,从补偿机制上来看,我国现有的政府补偿机制还存在许多漏洞,如缺乏科学依据,渠道不通畅等,主要表现在,政府补偿方向与基本需求的表达脱节等,由于我们对这些问题已经有了足够的认识,结合第四到第六部分的讨论,不同标准与方式的优劣比较,那么未来的补偿政策将在这些方面做出改变;第四,政府补偿不仅仅需要满足经济学当中的成本效率、成本效果等标准。政府作为国家的权利机构,有义务维持政权的稳定,国家正常运作,那么从政治学的角度出发,政府的公共卫生补偿需要与其他的财政补偿,如教育,国防等其他部门分享有限的财政资源,那么农村卫生补偿政策另一个不可忽视的重要内容在于,在国家健康发展的前提下,保证农村卫生补偿的可持续增长。第五,消除贫困是国际上目前普遍关注的问题,消除健康贫困也是政府农村卫生补偿政策的伦理学目标。因此,农村医疗救助制度是农村卫生补偿政策不可缺少的重要组成部分,随着人类社会对健康权利的关注,贫困人群健康权的维护同样在补偿政策中得以体现,那么在未来的政策中,在这一部分我们还将看到一些显著的变化,如补偿原则的修改,补偿方式的改变等。
五、创新点
1、描述了公共卫生政府补偿政策的基本框架
2、从新的角度阐述政府对农村公共卫生补偿职责的划分与公共财政体制的关系
3、较系统的描述了农村公共卫生政府补偿的未来发展选择。
六、需进一步研究的内容
1、政府补偿与社会经济发展的关系
2、本文主要在省级层面的卫生部门进行了深入的访谈和数据的搜集,下一步的研究还需要针对中央和基层卫生部门关键政策制定和执行者的访谈来获取更全面的了解,另外,对财政部门官员的访谈也是具有重要意义的补充。
3、现在人们根据补偿对象和方式的不同简单的将政府对卫生事业的补偿分为供方补偿和需方补偿,但实际上两者并无法截然分开,通过研究我们发现医疗保险机构和基层卫生服务者都能够成为政府补偿的代理者,这说明两者存在一种相互替代的作用。但两者如何发生相互作用还需要进一步研究。
China is a society that separate city and rural area. The rural living and working environment is different with city. Government set a separate policy system for rural health development for a long time.
ⅠThe goals and background
Some cases make me consider about some questions that relate with government payment for public health, such as, Should government be responsible for rural public health? If the compensation is necessary, which ways could be taken? Which health insurance system is active? How to select for government? Can they change the live of population? We decided study on policy of government payment for rural public health. To answer these questions, we have to learn about the history and background of policy framework. Then, select few key issues to discus further and find the theories to support these views. Finally, put forward reasonable suggestions based on discussion and theories.
According to these questions and contents, we have to make literature review firstly. The goal is learn about the policy history for rural public health payment, the challenges and selected revolutions. Which level government should pay responsibility for rural public health payment? How about the relationship between central and local government? From the government, we can learn about the flow backs and the obstacles for rural public health payment through key person interview. Through investigation for health care institutes, learn about the standards and ways of government payment for supplies. Finally, we explore the relationship between health status and government payment through checking the national investigation result. These social methods are simple and operated for the team. we can get the goals of study through these methods. In other sides, as we get the support from MOH, we can invite experts to evaluate the reports and give us more valuable suggestions in the whole process. The contribution of the study lie on identifying the framework of government payment for rural public health, help select the way of payment and explore development of rural health insurance system to direct the future policy selection.
The increasing medical cost is the big challenge for Chinese health system. The increasing income level of individual is much lower than increasing medical expenditure level. In 1999, the individual income had increased by 288% and 222% in city and rural area than in 1990. Compare to clinical expenditure, the increasing rate is 625%. According to the data from National Bureau of Statistics of China, every family expends 1.92% of total income to health care service. In 1999, the rate had been 3.16%, and the poorer family, the higher rate. It is more difficult to compensate the health care service only depend on user fee. The health institutes face financial constrains and for the population, it is the necessary result of increasing self medical, decreasing the utility and access of health care. The equity of health care has been threatened and health demand could not be provided.
From the result of the three health care investigations, the population covered by health insurance has decreased from 30.2% to 23.6% in 1993– 1998. The lack of health insurance is more serious in rural area. In 1993, the population that enjoys the health insurance is 12.8%, but just only 9% population could accept the health insurance. Most of the people have to pay for health care services that they need. The disease burden has been increased.
That data show the health payment policy have some flow back for a long time, such as the payment framework is not good enough, the responsibility of government is not clear, the criteria of payment should be proved effectively, government should pay more attention to health care service in poor. Health payment policy is one of the key points in health reform progress. The evaluation criteria, such as access of health care, equity and effective, quality of health care, poor release, have been impacted by implementation of health payment policy. The effective health payment policy will make great contribution for the success of health reform.
The essay interviewed the framework of rural health payment from 1949, analysis the reason of health payment by using economic theory, political theory, and discussing the payment relationship between different level governments, the format of provider payment, and the development of supply payment through literature review, question investigation and deeply interview.
ⅡMethods
Data collection methods: literature review, deep talking with key person, question investigations
Data analysis method: describing and exploring, the concept and theory of economic, investment theory, cost theory, demand theory, limited resource, stakeholder analysis, valuable analysis.
Quality control: In the design and prepare period, we invited expert to discuses the topic and took the pre-investigation for making sure the feasible and science. We try to select the right individuals and groups to investigate. Making sure the valuable second-hand material that had been collected from Analysis Report of National Health Services survey, etc.
ⅢThe results
Draft the government health payment frameworks in different periods through induction of history literature and analysis the frameworks by using political theory. Make sure the development and direction of health payment policy and get the common policy characters in different time. The goal of policy is more and more clear and detail. Compare to the two goals described in different periods, we can get the conclusion. The responsibility of different level government is more and more clear. The financial decentralization had been the basic of health payment policy. Government gradually becomes the main body of health payment from 2002. Payment has become the main action to attract excellent staff. The people began explore more financial payment for health care providers from just based on institutes ability. The shortage of the original format is that the health care providers will get more financial payment through increasing beds and staff. The modern criteria are based on output of health care and utility. These changes show the development of society.
Analysis the important function, policy goal, coverage of research, challenge and standard of government health payment through using the theory of rural economic, public health, health investment, equity and effective. Discuss about the relationship among health provider, health insurance, utility of health care service and government payment. Finally, we get the basic theory framework of government health payment. Interview with policy makers and operators from different province and collect some key information to learn about the key impact elements, different character and problems.
In western province, the health payment need be supported by central financial and the ability of local government is limited. Health payment focused on renew of equipments, but the quality of staff and service should be improved by taking right payment way. In middle province, the interviewer hope to increase the degree of financial transfer, change the structure of health payment, strengthen the input for township hospital and other public health institutes and build the sustainable system of health payment. In east province, local governments have enough ability to pay for the rural public health, but the payment direction is not clear and the waste is serious. From these results, we can get the conclusion that the low equity and effective of government health payment is common challenge.
ⅣDiscussions
Due to the imbalance of health payment in different province, we classified the public health as four types. Global public health services (infection disease monitoring, STD and AIDS monitoring) usually are paid attention by international organization. National public health services should be paid by central financial. Regional public health and local public health should be paid by provincial and local government. In additional, central government should increase input to poor province and area through transfer payment.
Discussing about the health provider payment, how to pay for the different providers is the main topic in the sector. Some evidences show that if the payment is reasonable, private providers effectively provide public health services; if the payment is unreasonable, public providers also provide unnecessary public health services. Due to the different style providers exist, we have several payment ways to select. We suggest that budget payment based on health demand, government purchase and separate of revenue and expenditure.
Discuss about demand payment model. We describe and explain the structure of medical insurance, the political background of CMA and progress. We think that the clinical services should be the necessary item paid by government, design payment level according to health demand. Compare to the medical insurance in urban and rural area and describe the medical insurance in other countries for exploring the future way. Finally, put forward the basic budget principle for MFA and the development.
As conclusion, in the framework, we try to explore the future policy development. Firstly, we identified government as the payer. The relationship between different level governments affects the development of policy. As building public financial system, the relationship between central and local government must have some obviously changes. It is the necessary future that clears responsibility and the balance of revenue and expenditure. Secondly, from economic theory, some indexes that show the health status and coverage of primary health care had improved. But we don’t know whether the other indexes that show input also get reasonable increase or not. The policy development will focus on effective change the live of population through adjust the structure and basic direction of payment. Thirdly, there are some shortages of payment policy, such as lacking evidence for payment, but we have realized the problem. Contacting with discussion sectors, we compare different standards and ways of payment. The future policy will make more correct selection. Fourthly, the standards for government payment are not just the cost-effect ion. Political standards are another important standards. Government should be responsible for keeping the stable of society. So public health should share the financial resources with other public affair. Keeping sustainable development is another important goal for policy development.
ⅤThe creation of study
Describe the basic framework of rural public health payment policy From the new view, identify the relationship between public health payment and public financial system.
Describe the policy for the future.
一、研究目的与背景
在对农村公共卫生补偿政策进行回顾的过程中,存在一些疑惑,如政府对农村的公共卫生到底应该采取怎样的态度?政府补偿的理论基础是什么?如果政府补偿立足于社会责任与道义,那么将有限的财政资源用于建立大病医疗保障与救助是无可争议的;但如果政府补偿立足健康投资理论,目的是为了提高劳动生产力,那么应该建立怎样的农村健康保障制度才是积极有效的呢?政府补偿的标准与原则应怎么选择?另外,政府应该采取怎样的补偿方式,是按照传统方式通过对医疗服务提供方进行补偿降低农民的疾病负担,还是通过建立新型农村合作医疗和救助对农民采取直接的医疗价格补偿?政府对农村公共卫生的补偿未来走向应该怎样选择?政府所做的事情到底在多大程度能够改变农村居民的健康状况?这些问题让我决定对农村公共卫生的政府补偿政策进行深入研究。
我们首先要做的工作就是进行大量的文献整理与分析,目的是了解农村公共卫生补偿主体、补偿标准和补偿对象的变化;结合社会发展了解这些变化的必然性及对补偿政策发展带来的影响。并在此基础上进行理论分析,帮助我们了解为什么对农村公共卫生进行补偿,应该补偿多少;帮助我们选择农村公共卫生政府补偿的理念与科学原则;帮助我们理解政府补偿的目标
其次,从政府的角度,通过对政策执行者们访谈了解目前不同地区农村公共卫生政府补偿政策执行的障碍;通过现场观察、文献和典型案例调查了解政策执行过程中在政府各部门、农村公共卫生供方、需方中存在的障碍。
最后针对补偿政策的主要障碍,如公共卫生补偿与公共财政体制融合;供方补偿标准与方式的选择;需方补偿原则和方案的选择等问题通过讨论获得提示和可选的解决方案
本课题研究的重要意义在于通过对政府补偿框架的界定,补偿方式的选择、医疗保障制度的发展等内容的探索来指导未来农村公共卫生政府政策的选择。
现阶段,卫生保健成本的增加是我国卫生系统面临的严峻挑战之一,居民收入的增长速度远远低于卫生服务保健花费的增长速度。与1990年相比,1999年城市与农村个人收入分别增长了288%与222%。而同期的门诊服务费用增长却达到625%。根据国家统计局的数据,1985年平均每个农村家庭花费家庭总收入的1.92%用于健康保健,到1999年,这一比例提高到了3.16%,而且越贫困的家庭该比例就表现得越高。依靠消费者自付的方式来补偿卫生服务提供,变得越来越来困难,结果必然导致自我医疗比例增加、卫生服务利用率,可及性降低、健康公平性受到威胁、健康需要得不到满足等一系列问题。
从三次卫生服务总调查结果来看,有健康保障的人口比例从1993年的30.2%降到1998年的23.6%。这一问题在农村地区表现更为明显,在1993年,农村居民的健康保险覆盖率已经低至12.8%,到1998年仅9.5%的居民享有健康保障。大部分居民必须为他们所需要的所有卫生服务支付大部分费用。
这一系列的数据均说明,长期以来我国的卫生补偿政策确实存在一些问题,例如,补偿框架的结构的不完善;政府补偿职责不清;补偿标准缺乏依据;对贫困人群的卫生补偿不够重视等。由于卫生补偿政策是卫生改革进程中关键环节之一,用于对卫生改革做出评价的标准,如卫生服务可及性、公平与效率、服务质量、贫困缓解等因素都不同程度受到卫生补偿政策执行效果的影响。合理有效的卫生补偿会给成功的卫生改革做出巨大的贡献。
本文主要通过回顾建国以来农村卫生补偿的政策框架、理论分析政府对农村卫生补偿的原因,其中包括经济学、政治学和伦理学等多因素的影响和应该补偿的理论额度、结合文献综述,现状调查和访谈的结果,就各级政府之间的补偿关系、供方补偿的形式、需方补偿的发展趋势等问题展开深入讨论,并提出相应的政策建议。
二、方法
资料搜集方法:文献复习通过查询中华人民共和国卫生部、民政部、发展改革委员会网站,世界银行,世界卫生组织等网站了解国际经验与国内相关政策进展,通过对万方、CNKI等中外数据库的文献查询了解与主题相关的研究进展;关键人员的访谈;现场数据搜集。
资料分析方法:分类资料的统计描述与分析;经济学的概念与理论,通过对公共卫生投资,公共卫生成本测算和公共产品供求关系等方面的理论分析,来帮助解释政府补偿的重要意义,政府补偿的标准、方式选择的技术基础和政府补偿的理论额度等专题;政治学利益集团分析方法;价值分析方法等。
质量控制:在设计和准备阶段通过专家论证和预调查以保证调查方案的科学性和可行性;选择有代表性的研究对象;保证所选用的二手资料可靠性强,大多来自国家政府部门发布的统计年鉴、政策法规和中国卫生总费用研究报告。
三、结果
通过对历史文献的归纳与整理,绘制出我国不同历史时期的政府公共卫生补偿框架,并对其进行政治和伦理学分析;从卫生补偿政策的历史发展过程,总结归纳政策的发展趋势和方向:政府目标逐渐具体和明晰;各级政府职责逐渐清晰,以财政分权为基础财政政策框架成为政府卫生补偿政策的基础;农村集体经济对卫生的补偿在2002年的决定中已经彻底消失了,转变为各级政府对农村卫生事业的投入;在需方补偿政策上,政府投入将作为一个支撑点,明确了将合作医疗和医疗救助相结合的具体方式;在卫生机构财务管理政策方面,逐渐体现将税收和价格作为政策调控的重要手段;对卫生服务提供者的补偿方式逐渐由以能力为基础的财政补偿转变为探索多种形式的财政补偿等。
但是我们也看到,长期以来的公共卫生的政府补偿政策存在明显的,难以克服的缺陷,就是目的不明确,补偿原则模糊不清。
运用农业经济学、公共产品、公共卫生、卫生投资、公平与效率等多学科理论对政府对公共卫生,特别是对农村的公共卫生进行补偿的重要意义、补偿目标、理论范围、挑战和评价标准进行了全方位的论述。
通过对政府卫生补偿政策现状研究,了解目前农村公共卫生补偿政策的障碍与挑战。通过对不同地区东、中、西部资料的收集和关键人员的深入访谈,了解到现阶段政府对卫生补偿所考虑的主要因素、不同的特征和存在的问题。从调查结论来看,我国政府的卫生补偿仍然普遍存在技术效率和分配效率低下等问题,但不同地区问题的侧重点却有所不同。
四、讨论
针对我国公共卫生补偿政府职责不清,东、中、西部政府补偿不平衡等问题进行讨论,明确中央与地方政府的职责分工、改善转移支付方式与财政补偿制度。为了进一步明确各级政府职责,尝试把不同的公共卫生产品分为全球性公共卫生产品、全国性公共卫生产品、区域性公共卫生产品和地方性公共卫生产品。中央政府可以通过专项财政转移支付等方式对困难地区的区域性和地方性公共卫生产品进行适当的补偿。
针对供方补偿存在问题进行讨论很多经验证据表明,如果补偿合理,营利机构也能像公立机构一样提供预防保健服务;如果政府补偿存在问题,公立机构一样也会存在滥用药品和提供不必要的医疗服务等现象。由于我国存在多种提供者所有制形式,因此,针对不同的所有制形式,本文提出了不同的政府补偿方式,例如,对卫生提供机构采取以需求为基础的预算补偿方式;对私人所有的营利性机构采取政府购买的补偿方式等。由于受到政治因素的影响,如部门间政治利益等关系的影响,卫生服务提供机构所有权问题依然是社会争论的一个焦点,针对政府所有的提供机构采取收支两条线的补偿方式又被重新提出来。但是对于政府购买和收支两条线这两种政府补偿方式来说,由于受到社会条件、经济条件、技术条件等多方面的影响,目前并不适合广泛的推广和实施。
针对需方补偿存在的问题进行讨论通过对我国医疗保障制度结构分析、新型农村合作医疗制度建立的政治背景和制度基础,制度建设进展等方面的描述与解释,认为在新型合作医疗方案完善的过程中门诊服务应该是政府补偿不可缺少的内容;在有条件的地方,选择按比例递减的补偿方式;按健康需求设计合理补偿水平等。通过城乡需方医疗保障方式的比较和国际医疗保障计划的描述,探索未来农村需方补偿方式的发展方向。对于贫困医疗救助而言其探索的方向应该是扩大受益范围,重视临界贫困状态;克服部门利益局限性坚持以医疗保障制度为平台实施医疗救助;根据实际需求与财政能力相结合制定救助方案;明确界定贫困人群中最困难的人员和最急需的医疗支出。农村医疗救助政策原则应该得到修改和进一步完善。
作为一个政策研究的结论,在现有的框架下,我们尽力在补偿功能、机制、产出等方面去探索未来政策发展的方向。首先,政府作为公共卫生补偿的主体,补偿政策的发展受到主体间关系变化的影响。随着公共财政体制的建立,中央与地方政府之间的关系必然发生一些显著的变化。公共卫生补偿职责的进一步明确与收支平衡的调整是未来补偿政策必然的发展方向;其次,从补偿的成本效果上来看,由于政府对农村公共卫生补偿的主要目的还是期望能够在于改善广大农民的健康状态,减少城乡差异,提高初级卫生保健的覆盖面等,这些指标近几年来每年都有一定的改善,但与政府补偿的投入是否成正比,未来的政府补偿政策发展方向必然通过针对影响人们的生活的主要因素,调整政府财政补偿的基本方向与结构,让政府投入能够更有效的改变人们的生活;第三,从补偿机制上来看,我国现有的政府补偿机制还存在许多漏洞,如缺乏科学依据,渠道不通畅等,主要表现在,政府补偿方向与基本需求的表达脱节等,由于我们对这些问题已经有了足够的认识,结合第四到第六部分的讨论,不同标准与方式的优劣比较,那么未来的补偿政策将在这些方面做出改变;第四,政府补偿不仅仅需要满足经济学当中的成本效率、成本效果等标准。政府作为国家的权利机构,有义务维持政权的稳定,国家正常运作,那么从政治学的角度出发,政府的公共卫生补偿需要与其他的财政补偿,如教育,国防等其他部门分享有限的财政资源,那么农村卫生补偿政策另一个不可忽视的重要内容在于,在国家健康发展的前提下,保证农村卫生补偿的可持续增长。第五,消除贫困是国际上目前普遍关注的问题,消除健康贫困也是政府农村卫生补偿政策的伦理学目标。因此,农村医疗救助制度是农村卫生补偿政策不可缺少的重要组成部分,随着人类社会对健康权利的关注,贫困人群健康权的维护同样在补偿政策中得以体现,那么在未来的政策中,在这一部分我们还将看到一些显著的变化,如补偿原则的修改,补偿方式的改变等。
五、创新点
1、描述了公共卫生政府补偿政策的基本框架
2、从新的角度阐述政府对农村公共卫生补偿职责的划分与公共财政体制的关系
3、较系统的描述了农村公共卫生政府补偿的未来发展选择。
六、需进一步研究的内容
1、政府补偿与社会经济发展的关系
2、本文主要在省级层面的卫生部门进行了深入的访谈和数据的搜集,下一步的研究还需要针对中央和基层卫生部门关键政策制定和执行者的访谈来获取更全面的了解,另外,对财政部门官员的访谈也是具有重要意义的补充。
3、现在人们根据补偿对象和方式的不同简单的将政府对卫生事业的补偿分为供方补偿和需方补偿,但实际上两者并无法截然分开,通过研究我们发现医疗保险机构和基层卫生服务者都能够成为政府补偿的代理者,这说明两者存在一种相互替代的作用。但两者如何发生相互作用还需要进一步研究。
China is a society that separate city and rural area. The rural living and working environment is different with city. Government set a separate policy system for rural health development for a long time.
ⅠThe goals and background
Some cases make me consider about some questions that relate with government payment for public health, such as, Should government be responsible for rural public health? If the compensation is necessary, which ways could be taken? Which health insurance system is active? How to select for government? Can they change the live of population? We decided study on policy of government payment for rural public health. To answer these questions, we have to learn about the history and background of policy framework. Then, select few key issues to discus further and find the theories to support these views. Finally, put forward reasonable suggestions based on discussion and theories.
According to these questions and contents, we have to make literature review firstly. The goal is learn about the policy history for rural public health payment, the challenges and selected revolutions. Which level government should pay responsibility for rural public health payment? How about the relationship between central and local government? From the government, we can learn about the flow backs and the obstacles for rural public health payment through key person interview. Through investigation for health care institutes, learn about the standards and ways of government payment for supplies. Finally, we explore the relationship between health status and government payment through checking the national investigation result. These social methods are simple and operated for the team. we can get the goals of study through these methods. In other sides, as we get the support from MOH, we can invite experts to evaluate the reports and give us more valuable suggestions in the whole process. The contribution of the study lie on identifying the framework of government payment for rural public health, help select the way of payment and explore development of rural health insurance system to direct the future policy selection.
The increasing medical cost is the big challenge for Chinese health system. The increasing income level of individual is much lower than increasing medical expenditure level. In 1999, the individual income had increased by 288% and 222% in city and rural area than in 1990. Compare to clinical expenditure, the increasing rate is 625%. According to the data from National Bureau of Statistics of China, every family expends 1.92% of total income to health care service. In 1999, the rate had been 3.16%, and the poorer family, the higher rate. It is more difficult to compensate the health care service only depend on user fee. The health institutes face financial constrains and for the population, it is the necessary result of increasing self medical, decreasing the utility and access of health care. The equity of health care has been threatened and health demand could not be provided.
From the result of the three health care investigations, the population covered by health insurance has decreased from 30.2% to 23.6% in 1993– 1998. The lack of health insurance is more serious in rural area. In 1993, the population that enjoys the health insurance is 12.8%, but just only 9% population could accept the health insurance. Most of the people have to pay for health care services that they need. The disease burden has been increased.
That data show the health payment policy have some flow back for a long time, such as the payment framework is not good enough, the responsibility of government is not clear, the criteria of payment should be proved effectively, government should pay more attention to health care service in poor. Health payment policy is one of the key points in health reform progress. The evaluation criteria, such as access of health care, equity and effective, quality of health care, poor release, have been impacted by implementation of health payment policy. The effective health payment policy will make great contribution for the success of health reform.
The essay interviewed the framework of rural health payment from 1949, analysis the reason of health payment by using economic theory, political theory, and discussing the payment relationship between different level governments, the format of provider payment, and the development of supply payment through literature review, question investigation and deeply interview.
ⅡMethods
Data collection methods: literature review, deep talking with key person, question investigations
Data analysis method: describing and exploring, the concept and theory of economic, investment theory, cost theory, demand theory, limited resource, stakeholder analysis, valuable analysis.
Quality control: In the design and prepare period, we invited expert to discuses the topic and took the pre-investigation for making sure the feasible and science. We try to select the right individuals and groups to investigate. Making sure the valuable second-hand material that had been collected from Analysis Report of National Health Services survey, etc.
ⅢThe results
Draft the government health payment frameworks in different periods through induction of history literature and analysis the frameworks by using political theory. Make sure the development and direction of health payment policy and get the common policy characters in different time. The goal of policy is more and more clear and detail. Compare to the two goals described in different periods, we can get the conclusion. The responsibility of different level government is more and more clear. The financial decentralization had been the basic of health payment policy. Government gradually becomes the main body of health payment from 2002. Payment has become the main action to attract excellent staff. The people began explore more financial payment for health care providers from just based on institutes ability. The shortage of the original format is that the health care providers will get more financial payment through increasing beds and staff. The modern criteria are based on output of health care and utility. These changes show the development of society.
Analysis the important function, policy goal, coverage of research, challenge and standard of government health payment through using the theory of rural economic, public health, health investment, equity and effective. Discuss about the relationship among health provider, health insurance, utility of health care service and government payment. Finally, we get the basic theory framework of government health payment. Interview with policy makers and operators from different province and collect some key information to learn about the key impact elements, different character and problems.
In western province, the health payment need be supported by central financial and the ability of local government is limited. Health payment focused on renew of equipments, but the quality of staff and service should be improved by taking right payment way. In middle province, the interviewer hope to increase the degree of financial transfer, change the structure of health payment, strengthen the input for township hospital and other public health institutes and build the sustainable system of health payment. In east province, local governments have enough ability to pay for the rural public health, but the payment direction is not clear and the waste is serious. From these results, we can get the conclusion that the low equity and effective of government health payment is common challenge.
ⅣDiscussions
Due to the imbalance of health payment in different province, we classified the public health as four types. Global public health services (infection disease monitoring, STD and AIDS monitoring) usually are paid attention by international organization. National public health services should be paid by central financial. Regional public health and local public health should be paid by provincial and local government. In additional, central government should increase input to poor province and area through transfer payment.
Discussing about the health provider payment, how to pay for the different providers is the main topic in the sector. Some evidences show that if the payment is reasonable, private providers effectively provide public health services; if the payment is unreasonable, public providers also provide unnecessary public health services. Due to the different style providers exist, we have several payment ways to select. We suggest that budget payment based on health demand, government purchase and separate of revenue and expenditure.
Discuss about demand payment model. We describe and explain the structure of medical insurance, the political background of CMA and progress. We think that the clinical services should be the necessary item paid by government, design payment level according to health demand. Compare to the medical insurance in urban and rural area and describe the medical insurance in other countries for exploring the future way. Finally, put forward the basic budget principle for MFA and the development.
As conclusion, in the framework, we try to explore the future policy development. Firstly, we identified government as the payer. The relationship between different level governments affects the development of policy. As building public financial system, the relationship between central and local government must have some obviously changes. It is the necessary future that clears responsibility and the balance of revenue and expenditure. Secondly, from economic theory, some indexes that show the health status and coverage of primary health care had improved. But we don’t know whether the other indexes that show input also get reasonable increase or not. The policy development will focus on effective change the live of population through adjust the structure and basic direction of payment. Thirdly, there are some shortages of payment policy, such as lacking evidence for payment, but we have realized the problem. Contacting with discussion sectors, we compare different standards and ways of payment. The future policy will make more correct selection. Fourthly, the standards for government payment are not just the cost-effect ion. Political standards are another important standards. Government should be responsible for keeping the stable of society. So public health should share the financial resources with other public affair. Keeping sustainable development is another important goal for policy development.
ⅤThe creation of study
Describe the basic framework of rural public health payment policy From the new view, identify the relationship between public health payment and public financial system.
Describe the policy for the future.
引文
1、审视中国农村卫生工作面临的挑战世界银行中国农村卫生剪报系列
2、中国在卫生千年发展目标方面的进展世界银行中国农村卫生剪报系列
3、中国卫生系统——为什么改革势在必行世界银行中国农村医疗剪报系列
4、中国的卫生服务提供:综述世界银行中国农村卫生剪报系列
5、中国卫生领域的公共支出与政府的作用世界银行中国农村卫生剪报系列
6、农村医疗保险——迎接挑战世界银行中国农村卫生剪报系列
7、农村贫困地区政府卫生支出及对卫生机构补偿的变化趋势分析陈迎春韩雷亚1999年第一期《卫生软科学》
8、Getting Health Reform Right Marc J. Roberts, William Hsiao, Peter Berman , Michael R. Reich
9、项莉湖北省农村基本公共卫生与政府负担能力研究报告
10、世界卫生组织宏观经济与卫生人民卫生出版社北京2002年9月
11、石光,刘秀颖投资于健康的理念与策略
12、陈宁姗,李健政府卫生补助项目研究报告
13、房俊涌,优化卫生资源配置需要政策干预和市场调节双重作用.卫生经济研究,1997;5
14、吴松林,宏观卫生调控的手段和政策措施.中国农村卫生事业管理,1998;8
15、尹力,政府投入-效率与公平的保证.健康报,1998;10:10
16、世界卫生组织.2000年世界卫生报告.人民卫生出版社,2000
17、世界卫生组织.2001年世界卫生报告.人民卫生出版社,2001
18、2006年世界发展报告
19、王立基.美国近年卫生支出的结构性变化.中华医院管理,2001;17(2).127-128
20、卫生部卫生经济研究所.2005年中国卫生总费用报告
21、Jose-Luis bobadilla . Designing an Essential National Health Package . Finance & Development . 1993;9.10-13
22、Marty Makinen. Ensuring Access to Essential Services. World Bank Institute. Promoting knowledge for a better world. Protecting the vulnerable: The design and implementation of effective safety nets. December 4-15, 2000 - Washington, D.C.
21、刘远立,饶克勤,胡善联中国农村的“三个世界”与3种健康保障模式中国卫生经济2002. 4(21)
22、马进中国农村健康保障办法的发展趋势中国卫生资源2002.1(5)
23、刘远立,饶克勤,胡善联中国农村健康保障问题不容忽视中国卫生经济2002. 4(21)
24、刘远立,饶克勤,胡善联政府支持与农村健康保障制度中国卫生经济2002. 5(21)
25、刘远立饶克勤胡善联中国农村健康保障制度的现状分析中国卫生经济2002. 4(21)
26、张里程,吴明,李卫平中国农村社会转型对健康保障模式选择的影响中国卫生资源2003,3(6)
27、刘远立,饶克勤,胡善联因病致贫与农村健康保障,中国卫生经济2002. 5(21)
28、刘远立,饶克勤,胡善联农村健康保障制度与卫生服务,中国卫生经济2002. 5(21)
29、2006年一季度农村医疗救助工作季度监测报告
30、方为群,林全明等玉溪市妇幼保健公共卫生服务项目财政补偿范围及成本测算调研报告中国妇幼保健2002年第17卷
31、Neelam K. Sekhri,Managed care: The US experience, Special Theme– Health Systems, Bulletin of the World Health Organization, 2000, 78 (6)
32、Charlotte Muheki,National Health Accounts and Their Use in Informing Health Sector Reform
33、Jeffrey D. Sachs, Concept Paper Macroeconomics and Health Strategy (MHS) Work
34. Xingzhu Liu, PhD,David R. Hotchkiss, PhD, etc. Contracting for Primary Health Services: Evidence on its effects and a framework for evaluation
35.张拓红,冯文等,广东省48所营利和非营利医院的制度环境分析中国医院管理, 2005,3(25)
36.夏苏建,医保住院病人自付比例分析中国医院管理,2005,1(25)
37.潘宝骏,陈烈平等10个卫生院卫生服务情况的8种方法综合评价结果中国医院管理,2003,1(23)
38.郝模,信亚东等医院补偿机制恶性循环模型和协调发展政策思路模型定量论证中国医院管理,1998,1(18)
39.冯振翼等主编新编卫生经济学民族出版社2002年9月第一版
40.魏颖杜乐勋主编卫生经济学与卫生经济管理人民卫生出版社
41.赵郁馨主编2005中国卫生总费用研究报告卫生部卫生经济研究所
42.2003年世界发展报告变革世界中的可持续发展改进制度、增长模式与生活质量世界银行
43.毛正中中国农村多种健康保障形式研究报告2002
44.G.布鲁姆,汤胜南,中国政府在农村合作医疗保健制度中的角色与作用,中国卫生经济,2002(3):17-21
45.任苒中国农村公共卫生补助办法研究报告
46.Nigel Rice, Paul Dixon, et Derivation of a needs based capitation formula for allocating prescribing budgets to health authorities and primary care groups in England: regression analysis. BMJ2000:320:284-288
47.王禄生等,农村公共卫生筹资政策研究报告
48.郑文贵等,乡村医生行医行为及其补偿方式研究
49.挑战健康不公平-从理念到行动
50.程晓明主编卫生经济学人民卫生出版社
51.Pablo Gottret, George Schieber, Health Financing Revisited, The World Bank
52. Mills,A. Bennett,S. and Russell,S. (2001) The challenge of Health Sector Reform: What Must Governments Do? Hampshire: Palgrave.
53. Andrew Green, B.Ali, Resource allocation and budgetary mechanisims fordecentralized health systems: experiences from Balochistan, Pakistan Policy and Practice Bulletin of World Health Organization, 2000, 78(8)
54. Mills A et al. Health system decentralization: concepts, issues and country experience. Geneva, World Health Organization, 1990
55. Murray CJL, Kreuser J, Whang W. Cost-effectiveness analysis and policy choice: investing in health systems. Bulletin of the World Health Organization, 1994, 72:663-674.
56. Doherty J, van der Heever A, A resource allocation formula in support of equity and Primary health care. Johannesburg, University of Witwatersand, Centre for Health Policy, 1997, Paper No.47 (248-250).
57.Barkat A et al. Research study: unit costs of primary level health care facilities. Quetta, Second Familiy Health Project, British Council, 1997.
58. Rowling, C, 1994. The contracting process: Building new relationships in health care. In: Contracting in the Health Sector, Legal Research Foundation, The University of Auckland. 1994: 47-63.
59. Vining, A.R. and S. Globerman. 1999. Contracting-out health care services: A conceptual framework. Health Policy 46(1999)77-96.
60. Wooldridge,J. and S.D. Hoag.2000. Perils of pioneering: Monitoring Medicaid managed care. Health Care Financing Review 22(2):61-83.
61. The World Health Report 2002. Reducing Risks, Promoting Healthy Life. Geneva,World Health Organization, 2002
62. Ostlin P, Diderichsen F. Equity-oriented national strategy for public health in Sweden. A case study. Brussels, World Health Organization European Centre for Health Policy, 2001
63. Gordon D, et al. Inequalities in Health. ed. Bristol, The Policy Press, 1999.
64. Zollner H. National policies for reducing social inequalities in health in Europe. Scand J Public Health 2002;30:6-11.
65. Ministry of Health. Reducing Inequalities in Health. Wellington, Government of New Zealand, 2002
66. Department of Health. Tackling Health Inequalities. A Programme for Action. London, UK Government, 2003
67. National Institutes of Health. Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities. Volume 1. Fiscal Years 2002-2006. Washington DC, US Department of Health and Human Services, 2002
68. Hogstedt C, et al. Swedish Public Health Policy and the National Institute of Public Health. Scand J Public Health 2004;32.
69. Ministry for Health Social Services and Public Safety. Investing for Health. Belfast,Northern Ireland Assembly, 2002
70. Ministry of Social Affairs and Health, Finland. Government Resolution on the Health 2015 public health programme. Helsinki, 2001
71. National Advisory Committee on Health and Disability (National Health Committee).The Social, Cultural and Economic Determinants of Health in New Zealand: Action to Improve Health. Wellington, Ministry of Health, 1998
72. Ministry of Health. Indicators of Inequality. Classification and selection of ethnic health disparity indicators. Occasional Bulletin No 5. Wellington, New Zealand Government. Public Health Intelligence, 2001
73. McKeown K. A guide to what works in family support services for vulnerable families. Dublin, Department of Health and Children, 2000
74. Ministry of Social Affairs and Health. Strategies for Social Protection 2010.Helsinki, Ministry of Social Affairs and Health, Finland, 2001
75. Irish Government. Sharing in Progress. National anti-poverty strategy. Dublin,Stationery office, 1997.
76. Department of Health. Tackling Health Inequalities. Consultation on a plan for delivery. London, UK Parliament, 2002
77. Ministry of Health. Tackling Inequalities: Moving theory to action. Wellington, Government of New Zealand, 2004
78. Ministry of the Interior and Health. Healthy throughout Life– the targets and Strategies for public health policy of the Government of Denmark, 2002-2010.Copenhagen, Government of Denmark, 2002
79. Ministry of Social Affairs and Health, Finland. Government Resolution on the Health 2015 public health programme. Helsinki, 2001
80. Ministry of Health. The Danish Government Programme on Public Health and Health Promotion 1999-2008. Copenhagen, Danish Government, 1999
81. Ministry of Social Affairs and Health. Social Welfare and Health Report 2000.Helsinki, Finnish Parliament, 2000
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2、中国在卫生千年发展目标方面的进展世界银行中国农村卫生剪报系列
3、中国卫生系统——为什么改革势在必行世界银行中国农村医疗剪报系列
4、中国的卫生服务提供:综述世界银行中国农村卫生剪报系列
5、中国卫生领域的公共支出与政府的作用世界银行中国农村卫生剪报系列
6、农村医疗保险——迎接挑战世界银行中国农村卫生剪报系列
7、农村贫困地区政府卫生支出及对卫生机构补偿的变化趋势分析陈迎春韩雷亚1999年第一期《卫生软科学》
8、Getting Health Reform Right Marc J. Roberts, William Hsiao, Peter Berman , Michael R. Reich
9、项莉湖北省农村基本公共卫生与政府负担能力研究报告
10、世界卫生组织宏观经济与卫生人民卫生出版社北京2002年9月
11、石光,刘秀颖投资于健康的理念与策略
12、陈宁姗,李健政府卫生补助项目研究报告
13、房俊涌,优化卫生资源配置需要政策干预和市场调节双重作用.卫生经济研究,1997;5
14、吴松林,宏观卫生调控的手段和政策措施.中国农村卫生事业管理,1998;8
15、尹力,政府投入-效率与公平的保证.健康报,1998;10:10
16、世界卫生组织.2000年世界卫生报告.人民卫生出版社,2000
17、世界卫生组织.2001年世界卫生报告.人民卫生出版社,2001
18、2006年世界发展报告
19、王立基.美国近年卫生支出的结构性变化.中华医院管理,2001;17(2).127-128
20、卫生部卫生经济研究所.2005年中国卫生总费用报告
21、Jose-Luis bobadilla . Designing an Essential National Health Package . Finance & Development . 1993;9.10-13
22、Marty Makinen. Ensuring Access to Essential Services. World Bank Institute. Promoting knowledge for a better world. Protecting the vulnerable: The design and implementation of effective safety nets. December 4-15, 2000 - Washington, D.C.
21、刘远立,饶克勤,胡善联中国农村的“三个世界”与3种健康保障模式中国卫生经济2002. 4(21)
22、马进中国农村健康保障办法的发展趋势中国卫生资源2002.1(5)
23、刘远立,饶克勤,胡善联中国农村健康保障问题不容忽视中国卫生经济2002. 4(21)
24、刘远立,饶克勤,胡善联政府支持与农村健康保障制度中国卫生经济2002. 5(21)
25、刘远立饶克勤胡善联中国农村健康保障制度的现状分析中国卫生经济2002. 4(21)
26、张里程,吴明,李卫平中国农村社会转型对健康保障模式选择的影响中国卫生资源2003,3(6)
27、刘远立,饶克勤,胡善联因病致贫与农村健康保障,中国卫生经济2002. 5(21)
28、刘远立,饶克勤,胡善联农村健康保障制度与卫生服务,中国卫生经济2002. 5(21)
29、2006年一季度农村医疗救助工作季度监测报告
30、方为群,林全明等玉溪市妇幼保健公共卫生服务项目财政补偿范围及成本测算调研报告中国妇幼保健2002年第17卷
31、Neelam K. Sekhri,Managed care: The US experience, Special Theme– Health Systems, Bulletin of the World Health Organization, 2000, 78 (6)
32、Charlotte Muheki,National Health Accounts and Their Use in Informing Health Sector Reform
33、Jeffrey D. Sachs, Concept Paper Macroeconomics and Health Strategy (MHS) Work
34. Xingzhu Liu, PhD,David R. Hotchkiss, PhD, etc. Contracting for Primary Health Services: Evidence on its effects and a framework for evaluation
35.张拓红,冯文等,广东省48所营利和非营利医院的制度环境分析中国医院管理, 2005,3(25)
36.夏苏建,医保住院病人自付比例分析中国医院管理,2005,1(25)
37.潘宝骏,陈烈平等10个卫生院卫生服务情况的8种方法综合评价结果中国医院管理,2003,1(23)
38.郝模,信亚东等医院补偿机制恶性循环模型和协调发展政策思路模型定量论证中国医院管理,1998,1(18)
39.冯振翼等主编新编卫生经济学民族出版社2002年9月第一版
40.魏颖杜乐勋主编卫生经济学与卫生经济管理人民卫生出版社
41.赵郁馨主编2005中国卫生总费用研究报告卫生部卫生经济研究所
42.2003年世界发展报告变革世界中的可持续发展改进制度、增长模式与生活质量世界银行
43.毛正中中国农村多种健康保障形式研究报告2002
44.G.布鲁姆,汤胜南,中国政府在农村合作医疗保健制度中的角色与作用,中国卫生经济,2002(3):17-21
45.任苒中国农村公共卫生补助办法研究报告
46.Nigel Rice, Paul Dixon, et Derivation of a needs based capitation formula for allocating prescribing budgets to health authorities and primary care groups in England: regression analysis. BMJ2000:320:284-288
47.王禄生等,农村公共卫生筹资政策研究报告
48.郑文贵等,乡村医生行医行为及其补偿方式研究
49.挑战健康不公平-从理念到行动
50.程晓明主编卫生经济学人民卫生出版社
51.Pablo Gottret, George Schieber, Health Financing Revisited, The World Bank
52. Mills,A. Bennett,S. and Russell,S. (2001) The challenge of Health Sector Reform: What Must Governments Do? Hampshire: Palgrave.
53. Andrew Green, B.Ali, Resource allocation and budgetary mechanisims fordecentralized health systems: experiences from Balochistan, Pakistan Policy and Practice Bulletin of World Health Organization, 2000, 78(8)
54. Mills A et al. Health system decentralization: concepts, issues and country experience. Geneva, World Health Organization, 1990
55. Murray CJL, Kreuser J, Whang W. Cost-effectiveness analysis and policy choice: investing in health systems. Bulletin of the World Health Organization, 1994, 72:663-674.
56. Doherty J, van der Heever A, A resource allocation formula in support of equity and Primary health care. Johannesburg, University of Witwatersand, Centre for Health Policy, 1997, Paper No.47 (248-250).
57.Barkat A et al. Research study: unit costs of primary level health care facilities. Quetta, Second Familiy Health Project, British Council, 1997.
58. Rowling, C, 1994. The contracting process: Building new relationships in health care. In: Contracting in the Health Sector, Legal Research Foundation, The University of Auckland. 1994: 47-63.
59. Vining, A.R. and S. Globerman. 1999. Contracting-out health care services: A conceptual framework. Health Policy 46(1999)77-96.
60. Wooldridge,J. and S.D. Hoag.2000. Perils of pioneering: Monitoring Medicaid managed care. Health Care Financing Review 22(2):61-83.
61. The World Health Report 2002. Reducing Risks, Promoting Healthy Life. Geneva,World Health Organization, 2002
62. Ostlin P, Diderichsen F. Equity-oriented national strategy for public health in Sweden. A case study. Brussels, World Health Organization European Centre for Health Policy, 2001
63. Gordon D, et al. Inequalities in Health. ed. Bristol, The Policy Press, 1999.
64. Zollner H. National policies for reducing social inequalities in health in Europe. Scand J Public Health 2002;30:6-11.
65. Ministry of Health. Reducing Inequalities in Health. Wellington, Government of New Zealand, 2002
66. Department of Health. Tackling Health Inequalities. A Programme for Action. London, UK Government, 2003
67. National Institutes of Health. Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities. Volume 1. Fiscal Years 2002-2006. Washington DC, US Department of Health and Human Services, 2002
68. Hogstedt C, et al. Swedish Public Health Policy and the National Institute of Public Health. Scand J Public Health 2004;32.
69. Ministry for Health Social Services and Public Safety. Investing for Health. Belfast,Northern Ireland Assembly, 2002
70. Ministry of Social Affairs and Health, Finland. Government Resolution on the Health 2015 public health programme. Helsinki, 2001
71. National Advisory Committee on Health and Disability (National Health Committee).The Social, Cultural and Economic Determinants of Health in New Zealand: Action to Improve Health. Wellington, Ministry of Health, 1998
72. Ministry of Health. Indicators of Inequality. Classification and selection of ethnic health disparity indicators. Occasional Bulletin No 5. Wellington, New Zealand Government. Public Health Intelligence, 2001
73. McKeown K. A guide to what works in family support services for vulnerable families. Dublin, Department of Health and Children, 2000
74. Ministry of Social Affairs and Health. Strategies for Social Protection 2010.Helsinki, Ministry of Social Affairs and Health, Finland, 2001
75. Irish Government. Sharing in Progress. National anti-poverty strategy. Dublin,Stationery office, 1997.
76. Department of Health. Tackling Health Inequalities. Consultation on a plan for delivery. London, UK Parliament, 2002
77. Ministry of Health. Tackling Inequalities: Moving theory to action. Wellington, Government of New Zealand, 2004
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