建立和完善妇幼卫生营养保障之初探

【作者】 牟岩；

【导师】 李勇；

【作者基本信息】 财政部财政科学研究所 ， 财政学， 2011， 博士

【摘要】 提高妇女儿童健康水平是人类发展的共同目标。妇女儿童的生存、健康状况,反映一国人口的总体素质和文明程度,也是社会公平正义的重要标志。从这个角度看,提高妇幼卫生与营养水平既事关对人类最基本的生存与健康需求的满足,又是提升一个国家整体人口素质、人力资源水平以及发展潜力的有效途径,更是促进经济社会协调发展的重要手段。在我国医疗卫生体制改革的大背景下,政府在公共卫生与基本医疗服务筹资与管理中的主体责任已经逐渐明晰。提供安全有效、方便价廉的基本妇幼卫生与营养服务,是整体公共卫生与基本医疗服务框架设计的重要组成部分。鉴于此,政府应进一步明确其在基本妇幼卫生与营养服务领域的职责,采取切实有效措施,筹措必需的资金,加大保障力度,确保全体妇幼人员的基本卫生营养需求得到满足,从而促进国民健康水平的提高,实现健康公平。新中国成立以来,特别是改革开放以来,我国妇幼卫生与营养事业取得了长足进步,但是与经济社会发展水平和人民群众的需求相比,还有一定的差距。比如,政府在这一领域还存在一定缺位,公共部门提供的妇幼卫生与营养服务尚未形成完善的体系,很多基本服务还是由妇女儿童个人支付,从而造成了不同人群在利用服务水平和健康水平等方面存在不公平。因此,当前要解决的突出问题是,明确现阶段政府应保障的基本妇幼卫生与营养服务的主要内容,并在此基础上,研究政府应该如何主导筹资以及合理引导投入方向,各级政府间应如何配置资金,如何对提供服务者进行支付,以及如何管理公共部门,从而实现提高健康水平与改善公平的目标。本文尝试从上述问题入手,通过理论与实践的分析与总结,力图寻找解决上述问题的基本思路和政策措施,为决策者提供参考。本文首先在绪论中对研究范畴、方法、所做的创新尝试与未来研究方向进行了概述。第二章中论述了政府保障基本妇幼卫生与营养服务提供的理论依据,包括基本妇幼卫生与营养服务属于政府保障范畴的理论基础,满足包括弱势群体在内的妇幼卫生营养需求的社会公平理论,妇幼卫生与营养筹资及管理的基本模式选择理论,以及由此引出的提供服务中的问责机制等。本文第三章从公平视角通过对孕产妇和儿童死亡率、妇幼营养不良等情况的分析,探讨了当前我国妇幼群体的健康状况现存的主要问题：一是我国妇幼健康水平还有待进一步提高,孕产妇及儿童死亡率、营养不良发生率等主要指标都还有不同幅度的下降空间。二是我国妇幼健康水平在不同地域间、不同人群间存在着较大差异。孕产妇死亡率与儿童死亡率方面,指标水平与当地经济发展水平密切相关——经济欠发达地区死亡率指标偏高；在儿童营养方面,政府对营养不良的纠正性政策措施和营养健康工程(即营养干预)不系统、不到位,不仅落后的贫困地区儿童营养不良形势堪忧,而且营养不良也存在显著的地域性不公平,且近年来有加重的趋势。总的来看,当前一些简单有效、价格低廉的妇幼卫生与营养支持措施尚未建立健全,对广大妇女儿童健康的保障作用尚未充分发挥。妇幼群体主要依靠个人支付相应的服务费用,从而在一定程度上造成了妇幼健康水平的差异。第四章分析了造成妇幼健康结果不公平的体制因素,指出卫生公共资源配置的不公平和低效,是造成妇幼健康水平差异的主要原因。通过大量数据分析,本文揭示了各省之间,各省内的地市之间、区县之间的公共卫生资源配置普遍存在不公平的现状。政府资源配置并不能充分体现当地居民的卫生营养需求,而是与经济发展水平密切相关；而且,在过去几年间这种趋势不仅没有得到缓和反而有所加强。另一方面,政府资源在人群间的配置也存在不小的差异。上述状况的存在,主要是由于在市场经济体制下,公共财政在资源配置、促进基本公共服务均等化方面的作用还没有完全发挥出来。具体表现为：一是公共卫生资源在不同地区与人群间配置的差异较大；二是政府资源在卫生机构之间配置效率有待提高——公共资源向高端医疗机构倾斜,未能按成本效益原则更多补偿初级保健服务；三是政府间财政关系有待进一步完善,各级政府的财力与事权不匹配,卫生支出责任下移,以及对专项转移支付过度依赖等。本文接下来梳理了妇幼卫生与营养服务筹资和公共管理(包括对服务提供机构进行支付)的国际经验。首先,从全球范围看,在筹资模式选择上,不论发达国家,还是典型的、与中国有可比性的发展中国家,妇幼卫生与营养服务都以税收为主要筹资模式,辅以社会保险筹资(主要应对妇幼的基本医疗需求,必要时针对妇女儿童在健康保险中的保费和个人负担的医疗费用部分给予减免等)。在妇幼卫生与营养筹资模式选择中,为了不给贫困家庭造成灾难性支出,很多国家对妇女儿童及人口中其他弱势群体都实行了服务费用的减免。完全依赖个人付费的筹资模式,主要针对满足特殊需求的私人服务。在这方面,国际上有很多经验可以借鉴。其次,我们要充分认识营养干预对于国民健康素质与整个国家发展的重要作用,积极总结国际上切实有效的营养干预方案,制定全国性的规划与实施战略。最后,国外关于妇幼卫生与营养服务的供方支付模式为我们提供了经验借鉴。服务提供方行为直接影响到服务利用者的经济负担,目前我国还普遍使用按服务项目付费的支付方式,不仅导致了卫生资源的浪费,还会加重患者负担,影响了卫生资源的配置效率和服务利用的公平性。很多国家针对初级保健、医院服务等不同类型服务,对供方补偿方式进行了有益的探索,并积累了很多有益的经验,值得我国借鉴。如上所述,在对国内妇幼卫生与营养保障的现状、问题与成因进行分析后,借鉴相关国际经验,本文最终提出了现阶段保障我国妇幼卫生与营养筹资及提供的基本思路和政策措施：1、在服务筹资方面,坚持以税收筹资为主。在公共服务筹资模式中,税收筹资模式更具公平性,也更适合我国妇幼卫生与营养服务的状况和发展需要；同时可辅以社会保险筹资,但对贫困妇女儿童要设置必要的保费和自付部分的减免措施；个人付费筹资模式的使用,应仅限于满足个人特殊需求的非基本妇幼卫生与营养服务。2、基于对国内经济社会发展阶段与资金筹集能力的判断,依据国内妇幼卫生与营养现状,参考国际最佳做法,现阶段我国基本妇幼卫生与营养服务包应主要包括孕产妇保健与营养类、儿童保健与营养类、孕产妇与新生儿医疗类、生育期妇女保健服务类、全民性妇幼健康促进类等五大类服务。3、为改善服务提供的公共管理机制、纠正政府资源配置不公与低效,今后一个时期,应重在建立完善政府问责制、改革地方服务提供的绩效考评、加强包括妇幼在内的公众参与等。4、现阶段要进一步改革妇幼卫生与营养服务的供方支付方式,允许不同服务机构选择不同的方式,强调应因地制宜,注重效果评价,并保障充分的调整空间。5、要加强并进一步完善当前妇幼卫生与营养的监测和数据信息体系建设。更多还原

【Abstract】 It is a momentous objective for the entire human race to continuously improve the health status of women and children. From this perspective, to improve the health and nutrition status of women and children is not only to meet the essential rights of human beings to survival and good health, but also a necessary means to advance civilization of the society, and to realize social fairness and justice. The delivery of essential health and nutrition services for women and children will effectively improve the overall population quality of the nation, advance human resource development, as well as promote a well-balanced and coordinated social and economic development of the nation. Against the backdrop of ongoing health sector reform in China, the primary role of financing and governance for the delivery of public health and essential clinical services is gradually clarified to be government accountability. With safe, effective, convenient and affordable essential health and nutrition services for women and children being important components of the public health and essential clinical services, delivery of these services should be guaranteed and secured by the government. At current stage, the Government should further clarify its due roles and responsibilities in securingessential health and nutrition services for women and children, to adopt practical and effective policy measures and to raise sufficient funds, so as to meet the basic needs of women and children, to promote the health status of the citizens, and to realize health equity.After the People’s Republic of China was founded, particularly since the economic reforms, tremendous improvementshave been achieved in health and nutrition status for women and children. The health and nutrition status, however, is yet to meet the requirements posed by economic and social development, as well as the actual needs of the people. Currently the government is not providing essential health and nutrition services for women and children in a systematic and comprehensive manner. Inadequate public financing and under-delivery ofcertain essential services results in high level of out-of-pocket payment by women and children in need, which is the root cause for inequity in service utilization and health outcomes. It is of paramount importance to define what services should be included in an essential package of health and nutrition services for women and children that the Government should secure at the current stage. Meanwhile, a number of questions remain unanswered:how the government should lead and reform the financing for the services, how to allocate the fund among different tiers of governments, how to choose provider payment schemes, and how to optimize public sector governance, so as to not only improve the overall health for women and children, but also to improve health equity among different socio-economic groups. The dissertation attempts to answer these questions, and provide proposals and recommendations in resolving the issues through both theoretical and practical analyses.The first chapter of the dissertation provides an overview on the research scope, methodologies, innovations and prospects. In the second chapter, it analyses the theoretical framework for the government to secure the delivery of essential health and nutritionservices for women and children. It discusses why these essential services should be secured by the government, how it fits the social fairness theory that the State should meet the needsfor women and children, including the most vulnerable ones, in their claims foressential health and nutrition services, the conceptual models for financing and governance of health and nutrition services for women and children, the theoretical framework for accountability of service delivery, etc.ChapterⅢoffers a comprehensive analysis of the status quo forwomen and children’s health and nutrition in China, with an emphasis on the existing challenges. Currently the status for woman and child health, measured mainly by maternal and child mortalities, is predominantly featured by the following two characteristics:(1)Evident room for improvement is still seen in maternal and childhealth:maternal and child mortality ratios are still to be further reduced; (2)Large disparities exist across geographical regions and amongst socioeconomic population groups:the mortality ratios are found to be negativelyrelated with the local GDP per capita, i.e. Significant geographic inequity in health outcome. In the area of maternal and child nutrition, due to the lack of comprehensive public interventions to address malnutrition, the overall situation is worrying, i.e., predominant child malnutrition still prevails in least developed rural regions, whilst the disparities increase over years between better off and less off regions. In general, a series of simple, inexpensive but effective nutrition interventionshave not been delivered, leaving manymaternal women and children unprotected from malnutrition and bad health risks, and inequity prevails. This problem of lack of available public services also leads to over-dependence on out of pocket (OOP) payment in utilization of necessary health and nutrition services by women and children, which eventually results in inequitable maternal health and nutrition outcomes.ChapterⅣprobes into the public finance factors that account for the inequity in health and nutrition outcomes. The author argues, the inequitable and inefficient public resource allocation should explain for the inequitable health outcome to alarge extent. Analyses of a large amount of local spending data revealthat, the inequitable allocation of public resources widely prevail across provinces, across prefectures and counties within provinces:On the one hand, the government resources are not always allocated based on needs for health and nutrition services by the citizens, but more according to the economic development status of the localities. This worrying trend is intensifying over the past decade. On the other hand, public resources are not allocated amongst population groups equitably either. In summary, pubic finance is not playing its due role in promoting resource redistribution and equalization of essential social services under the current market economy regime. In addition to the inequity problem, the government resources are not allocated efficiently either, i.e., resources allocation disproportionally favourstertiary clinical institutions, which are located in cities mostly, whilst primary care institutions do not get sufficient resources based on cost effectiveness principle. Moreover, intergovernmental fiscal relations are problematic, in a waythat the health spending duties are greatly decentralized to local governments, and there is over-reliance on earmarked fiscal transfer as opposed to general purpose (equalization) transfers in the health sector.The dissertation then reviews the international experiences of financing and governance (including choice of provider payment schemes) for health and nutrition services for women and children. In choosing financing modes, international review suggests that, no matter developed countries or developing countries that areat comparable development stages with China, taxation financing for woman and child health and nutrition is the primary modality. Social insurance financing plays a supplementary role, mainly to meet the essential clinical needs for women and children. Waiver in premium and copayment to the poor women and children has been a common practice. Out of pocket payment could be used to cover special services needed by special groups of women and children. Its use, however, should not lead to catastrophic health spending to poor households either. In practice many countries offer waiver or deduction in OOP to such population groups as maternal women and/or children.International review of public policies and interventions on nutrition for women and children offers a good deal of useful implications for China. Recognizing how nutrition interventions could contribute to the overall improvement of citizens’ health status as well as the nation’s socio-economic development, China should design national planning and implementation strategies for nutrition intervention and promotion, taking into accountsboth thepractices proven cost-effectiveinternationally, and the domestic realities.The dissertation also investigates into the provider payment schemes, which directly affects the economic burden of the service users. The traditional provider payment scheme in China’health sector, i. e. fee for services, has been widely criticized for causing huge waste in the use of health resources, and imposing heavy burden on patients and service users. The choice on provider payment schemes has direct impact on the allocation efficiency of health resources, as well as the level of service utilization by citizens including women and children, and thus has equity implications. Rich experiences accumulated by various countries in provider payment schemes for various types of services (i.e. primary care, hospital services) offer good reference for China to draw from.Based on the above analyses of existing issues and investigation into the causes of the issues, as well as the rich international experiences and lessons, the dissertation draws a comprehensive policy framework for the financing and management of essential health and nutrition services for women and children.(1) Taxation should be primary source of financing for the health and nutrition services. Taxation financing is more equitable, and a better fit for China in securing services for women and children as well as the nation’s development needs. Social health insurance can be a supplementary financing source for basic medical services for women and children. However, necessary waivers for premium and copayment should be granted to poor women and children. Financing by pure out of pocket payment should only be used to meet private needs for non-basic maternal and children health and nutrition services.(2) In view of the current socio-economic development stage and the public financing capacity in China, as well as the status quo of health and nutrition status for women and children, with reference to international best practices, the dissertation outlines the contents in an essential package of health and nutrition services for women and children, which includes five major categories such as maternal health and nutrition services, child health and nutrition services, maternal and new born basic medical services, health services for women at fertility ages, and general public health promotion services. (3) Thedissertation offers policy recommendations on how to address the inequitable and inefficient public resource allocation and public sector governance:enhancing governmentaccountability scheme for service delivery, reforming performance evaluation for local government in delivering services, and increasing participation of citizens particularly from women and children, etc.(4) It is then proposed that in the current reforms of provider payment schemes for health and nutrition services, different types of institutions should use different provider payment modalities to achieve respective policy goals. Local realities should be taken into serious consideration when new payment schemes are introduced, and results should be constantly monitored and evaluated to allow timely adjustments.(5) It is recommended the current maternal and children health and nutrition surveillance statistical and information system be improved and strengthened.更多还原