【作者】 于风华；

【导师】 孟庆跃； 王健；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2011， 博士

【摘要】 我国三十多年的卫生改革与发展取得了巨大成就,人民健康状况明显改善。但是,卫生事业仍滞后于经济和其他社会事业的发展,群众看病贵、看病难的问题突出。过度依赖使用者付费的卫生筹资体制是制约我国卫生改革与发展的主要矛盾之一。新时期,党和政府确立了以人为本的科学发展观,致力于构建“全民覆盖”的基本医疗卫生制度。2009年,《中共中央、国务院关于深化医药卫生体制改革的意见》提出“逐步提高政府卫生投入占卫生总费用的比重,使居民个人基本医疗卫生费用负担有效减轻”的筹资承诺。卫生筹资是世界各国面临的普遍问题和巨大挑战。卫生总费用是开展卫生筹资政策评价的重要工具。某种程度上,山东是中国的缩影。山东开展亚国家级卫生费用核算,从理论上进行系统研究,将丰富亚国家级卫生总费用核算理论体系,具有一定的学术价值。我国卫生投入以地方为主,亚国家级(地区级)卫生费用核算对服务地方卫生改革具有更大的价值。目前,山东省卫生总费用核算研究尚处于空白。运用学界认同的核算方法,对山东省卫生总费用核算研究,为建立适合山东的卫生筹资策略和卫生筹资机制提供基本理论、政策建议和实证依据,具有一定的政策应用价值。相对于国际研究,我国卫生总费用核算研究起步较晚,但近年发展较快,研究成果较多。但运用指数平滑法预测卫生总费用未来发展趋势,目前国内尚缺乏这方面的系统研究。本研究的总目标是测算1998-2009年山东省卫生总费用,为卫生改革与发展提供卫生筹资方面的信息。具体目的包括：测算山东省卫生总费用,分析山东省卫生总费用主要构成及其特点,预测山东省卫生总费用未来变化趋势,提出改善卫生筹资政策的建议。资料来源与方法数据资料主要来源于：《山东统计年鉴》、《山东卫生统计年报资料》和《山东卫生财务年报资料》。有些数据到相关部门进行调查、访谈,个别数据利用现有资料及相应的参数进行估算。数据收集涉及的部门主要包括：省统计局、省卫生厅、省财政厅、省劳动和社会保障厅、省医保局、省保监委、省红十字会、省民政厅、省残联和省慈善总会等机构。本研究采用筹资来源法和机构流向法测算山东省卫生总费用；利用Holt-Winters指数平滑法,预测分析卫生总费用未来发展趋势；利用Gini系数分析工具,测量卫生事业费地区分布的公平程度。比较研究增长速度时,采用GDP指数进行调整,消除不同年度的价格影响。比较研究国际间卫生总费用时,按购买力平价计算,消除国际间的价格影响。资料采用Excel 2003软件进行统计描述分析,用Eviews6.0软件进行预测分析。主要核算研究结果(1)1998-2009年,山东省卫生费用筹资总额从195.71亿元增加到1163.20亿元；人均卫生总费用从221.44元增加到1228.26元；卫生总费用占GDP的比例从2.79%增加到3.43%；卫生费用年均增长速度为12.62%,但各年度增长差异较大。(2)1998～2009年,按照国内口径,政府卫生支出和社会卫生支出占卫生总费用的比重分别从15.67%和28.93%增加到21.84%和36.85%,OOP占的比重从55.40%降低到41.31%；按照国际口径,广义政府卫生支出占卫生总费用的比重从36.95%增加到45.62%,私人卫生支出占的比重从63.05%降低到54.38%。(3)从卫生费用分配来看,2009年约七成的卫生费用流向医疗机构,约一成的费用流向公共卫生机构。基层医疗机构(社区卫生机构和卫生院)占分配总额的比重为7.48%。(4)1998-2009年,药品费用从113.89亿元增加到499.08亿元,人均药品费用从128.86元增加到527.01元,药品费用占卫生总费用的比重从47.19%降低到43.83%。药品费用年均增长速度为11.63%,慢于GDP增长速度。(5)1998-2009年,山东省政府卫生支出从30.66亿元增加到254.02亿元；人均政府卫生支出34.70元持续增加到268.23元；政府卫生支出占卫生总费用比重从15.67%增加到21.84%。政府卫生支出年均增长速度为18.29%,快于GDP、卫生总费用和财政支出年均增长速度。按照国际口径,山东省广义政府卫生支出占GDP比重从1.03%增加到1.57%,人均广义政府卫生支出从22.46美元增加到138.52美元。(6)1998-2009年,山东省卫生事业费从17亿元增加到77.90亿元,人均卫生事业费从17.70元增加到82.94元,卫生事业费占卫生总费用比重从8.69%降低到6.70%,卫生事业费占财政支出比重从3.48%降低到2.38%。卫生事业费年均增长速度为12.09%,慢于地方财政支出增速约4个百分点。(7)2009年,卫生事业费在医疗卫生机构的分布为：城市医院占30%、县级医院占12%、乡镇卫生院占15%、城市社区卫生机构占2%、疾病预防控制机构占18%、卫生监督机构占3%、妇幼保健机构占2%、其他卫生机构占18%。2000～2009年,山东省17市卫生事业费Gini系数由0.2增加为0.372,地区差异拉大。2009年,140县(市区)卫生事业费Gini系数为0.31。(8)2000-2009年,山东省城镇职工基本医疗保险基金收入从8.40亿元增加到190.23亿元,其占卫生总费用比重从3.09%增加到16.77%；2003-2009年,新型农村合作医疗基金收入从0.60亿元增加到66.41亿元,其占卫生总费用比重从0.15%增加到5.71%。(9)1998-2009年,城镇居民人均OOP从184.92元增加到727.70元,农村居民人均OOP从84.64元增加到301.55元；城镇居民人均OOP占家庭非食品支出的比重从7.39%增加到9.03%,农村居民人均OOP占家庭非食品支出的比重在10%-12%之间波动。2009年,城镇居民收入最低的10%家庭组其OOP占家庭非食品支出比重最高(11.05%)。(10)预测2015年和2020年山东省卫生总费用分别为2219.38亿元和3099.53亿元,卫生总费用占GDP的比重分别增长为4.01%和4.25%,OOP占卫生总费用的比重分别降低为37.02%和35.47%。结论和政策建议将山东省卫生总费用核算结果与国内外开展比较研究,得出以下结论：山东省卫生筹资代表贫穷国家(或地区)的筹资水平。卫生事业发展滞后于社会经济发展。山东省卫生筹资构成向着好的方向变化,但卫生筹资构成仍不合理,公共筹资不足、个人筹资较高。山东省政府卫生支出增长速度高于财政支出增长速度,但与全国相比,山东省政府卫生支出水平较低。山东省卫生事业费投入水平较低,市际之间财政补助的不公平性程度增强。山东省OOP占卫生总费用的比重呈下降趋势,但城乡居民的实际医药费用负担水平并没有下降,反而升高。相对于城镇居民,农村居民的医疗费用负担较重；相对于高收入家庭,城镇居民低收入家庭的医疗费用负担较重。山东省药品费用占卫生总费用比重呈下降趋势,但药品费用占卫生总费用比重仍较高,距离国际先进水平仍有很大差距。预测未来10年,卫生总费用占GDP的比重逐年提高,OOP占卫生总费用的比重逐年降低,但卫生总费用占GDP的比重仍较低,OOP占卫生总费用的比重仍较高。基于以上结论,提出以下政策建议：(1)大力发展地区经济,努力筹集足够的卫生资金,提高卫生总费用占GDP的比重,保持卫生事业与社会经济的协调发展。(2)随着经济的发展,调整财政和卫生筹资政策,政府切实承担起卫生投入的主要责任。结合新医改,用“大卫生”的观点统筹卫生工作,采取补供方和补需方相结合的混合型筹资模式,进一步提高公共筹资比例、降低个人筹资比例,优化卫生筹资构成。(3)提高卫生事业费投入水平。中央和省级加大对地方的财政转移支付力度,提高地区间财政补助的公平程度。(4)加强医药费用控制、减少浪费和提高居民收入水平,控制OOP负担水平；同时,对农村居民和城镇低收入居民等弱势人群,通过医疗救助制度等政策措施,给予重点保护,确保弱势人群卫生服务的可及。(5)推行基本药物政策,充分补偿基层医疗机构,减弱或消除医疗机构(医生)对药物不合理使用的经济激励,确保基本药物的合理使用,以减少浪费、控制药品费用。更多还原

【Abstract】 The health care reform and development has achieved a significant progress since last three decades. The health status has been significantly improved as well. However, the progress of health and care was behind the social and economic growth. The so called "difficult and expensive to see a doctor" is still a major problem. It is one of main barriers to reform the health care in terms of fact of the fee for service payment in health financing. The recent government promotes the goal of People-oriented scientific development and devotes itself to build the universal coverage for the national basic health care system. In 2009, the party central committee and the state council on deepening the reform of medical care system in opinion promises gradually increase the proportion of government health expenditure over the national health expenditure and control the out of pocket with an affordable ability.The health financing is a general and common problem and challenge in the world. Total Health Expenditure is an important tool to evaluate the impact of health financing policy. To certain extend, Shandong province is a picture of the whole China. The analysis of sub-national health expenditure is a scientific contribution though theoretical studying health expenditure in Shandong. At present, there is no research regarding sub-national health expenditure in Shandong. It is a significant policy implication through the study to provide evidence-based health financing for the policy making. Comparing with the international study, the analysis of total health expenditure is relatively new. However, it achieves a significant progress. In addition, the applying of Exponential smoothing method to forecast the future trend of the total health expenditure is new as well. This study wishes to contribute the significance of the application.The objective of the study is to measure the total health expenditure from 1998 to 2009 in Shandong province. The specific objectives are as follows:(a) analyzing the major components and their characteristics of Shandong total health expenditure through measuring; (b) forecasting the future trend of Shandong total health expenditure in order to recommend improving the health financing policy in Shandong.Source and methodThe data sources are from Shandong Statistical Yearbook, Shandong Health Statistics Annals Reports, and Shandong Health Financial Annual Reports. Some data sources are estimated basing on parameters through investigation, interview, and gray literatures. The data collection associated with the departments as such Statistical Bureau, Health Bureau, Department of Finance, Department of labor and Social Security, Medical insurance bureau, Insurance Regulatory Commission, Red-cross, Bureau of Civic Affair, Disabled Persons’ Association, and charity Association. Holt-Winters exponential smoothing method is used to forecast the future trend of total health expenditure. The Gross Domestic Product (GDP) index is adjusted to reduce the pricing impact cross years when comparing the increasing growth rate. The Purchasing Power Parity (PPP) is used to the pricing impact crossing counties when comparing the country-specific total health expenditure. In addition, Excel 2003 is managed to provide descriptive analysis. Furthermore, Eviews 6.0 is used to forecast the trend.Research results(1) The total health expenditure has been increased from 19.571 billion RMB in 1998 to 116.32 billion RMB in 2009. The total health expenditure per capita has been increased from 221.44 RMB to 1228.26 RMB for the same time period. The total health expenditure over GDP is increased from 2.79 per cent to 3.43 per cent. However, the growth rate is varied across years.(2) The government expenditure and the social expenditure over total health expenditure is increased from 15.67 per cent and 28.93 per cent to 21.84 per cent and 36.85 per cent from 1998 to 2009 respectively. The proportion of out-of-pocket expenditure is decreased from 55.04 per cent to 41.31 per cent with the domestic standard. In addition, the proportion of general government expenditure over the total health expenditure is increased from 36.95 per cent to 45.62 per cent, the proportion of private health expenditure is decreased from 63.05 per cent to 54.38 per cent with the international standard.(3) From the perspective of health expenditure allocation, more then 70 per cent of the resource is allocated to providers and 10 per cent is allocated into public health facilities.7.48 per cent is allocated to primary level facilities including community primary health center and township hospital.(4)From 1998 to 2009, drug expenses are increased from 11.389 billion RMB to 49.908 billion RMB. The drug expense per capita is increased from 128.86 RMB to 527.01 RMB. The proportion of drug. expense over total health expenditure is decreased from 47.19 per cent to 43.83 per cent. The growth rare of drug expense is 11.63 per cent which is less than the growth rate of GDP.(5) From 1998 to 2009, the Shandong government health expenditure is increased from 3.066 billion RMB to 25.402 billion RMB. The government expenditure per capita is increased from 3.47 RMB to 268.23 RMB. The percentage of government expenditure over the total health expenditure is increase from 15.67 to 21.84. The growth rate of government expenditure on average is 18.29 per cent which is on average more than GDP, total health expenditure, and financial expense respectively. In accordance with the international standard, the proportion of the general government expenditure over GDP is increase from 1.03 to 1.57. In addition, the government expenditure per capita is increased from US$22.46 to US$138.52 respectively.(6) From 1998 to 2009, the recurrent expense of health is increased from 1.7 billion RMB to 7.79 billion RMB. The recurrent expense of health per capita is increased from 17.70 RMB to 82.94 RMB. The proportion of recurrent expense of health is decreased from 8.69 to 12.09, while, over the fiscal expenditure is decreased from 3.48 to 2.38. The average growth rate of the operational expense is 12.09 per cent which is less than 4 per cent of the local fiscal expenditure.(7) In 2009, the distribution of the recurrent expense of health is as follows; 30% in urban hospital,15% in township hospital,2% in community health center,18% in CDC,3% in health supervision facility,2% in maternal care facility, and 18% in other health institutions respectively.From 2000 to 2009, the Gini coefficient of total health expenditure is increased from 0.2 to 0.372 among 17 prefectures which shows a relative high variation in Shandong. In addition, it is 0.31 among 140 counties in 2009.(8) From 2000 to 2009, the funds of urban employee basic health insurance are increased from 840 million RMB to 19.023 billion RMB. The proportion of over GDP is increased from 3.09 per cent to 16.77 per cent. In addition, the fund of new medical cooperative scheme (NCMS) is increased from 600million to 6.641 billion which represents the increasing percentage from 0.15 to 5.71.(9) From 1998 to 2009, the average OOP for urban resident is increased from 184.92 to 727.7 RMB, while, it is on average from 84.64 to 301.55 RMB for rural resident. The proportion of average urban resident OOP over the household non-food consumption is increased from 7.39 to 9.03, while, it is from 10 to 12 for rural resident. In 2009, the proportion of OOP over household non-food consumption for 10 percentage of the lowest household income group is the highest which is 11.05.(10) From 2015 to 2020, the forecasting of total health expenditures from 2015 to 2020 is 221.938 billion and 309.953 billion respectively. The proportion of total health expenditure over GDP is increased 4.01% and 4.25% respectively. The proportion of OOP over total health expenditure is decreased 37.02% and 35.47% respectively.Consultation and policy recommendationAfter comparing the outcome of measuring Shandong total health expenditure with the domestic and international study, this study finds the main conclusions as follows;The health financing in Shandong represents the low level which is similar with the poor developing countries (or area). The development of health is far behind the economic growth.The composition of health financing in Shandong tends to be a positive change. However, it still shows an inappropriate composition, insufficient public financing, and the relative high OOP.On average, the increasing rate of government expenditure is more than fiscal expenditure. However, it is still in a relative low level when comparing with other provinces. In particular, it is both low in the recurrent expense of health. The inequality of financial subsidy among prefectures shows an increasing level. However, we did not find this similar result among counties.The proportion of OOP over total health expenditure tends to decrease. However, the real level of medical expense burden is not decreasing. On the contrary, it tends to increase. Comparing to urban resident, rural resident pays a relative high medical expense. Comparing with relative high income household, it is a relative high burden for low income household.The drug expense over total health expenditure tends to decrease. However, it is still in a relative high level and a big gap with the developed countries. The result of forecasting shows that the proportion of total health expenditure over GDP is to gradually increase and of OOP over total health expenditure is to gradually decrease. However, the total health expenditure over GDP is still in a relative low level. The proportion of OOP over total health expenditure is relative high.Basing on the above conclusions, this study recommends as follows:(1) The goal of collecting more health resource relies on the rapid economic development. This could increase the proportion of total health expenditure over GDP and then it turns to coordinate the development of health and social economy.(2) The government need to increasingly recognize the role of investing in health, adjusting the fiscal and health financing policy, increasing government investment in health. In line with the ongoing health care reform, the perspective of "macro health" could be used to generate the financing in order to increase the government expenditure. A mix of subsiding providers and reimburse demand side method should be used to improve the social security level, in order to further increase public proportion, reduce individual proportion, and appropriately restructure the components.(3) As regards to operational health expenditure, this study suggest increasing the recurrent expense of health. There is a strong need to increase the level of central and provincial government transfer to local to balance the discrepancy across prefectures and to increase the fairness of financial subsidy.(4) The role of reducing OOP should be achieved through controlling the drug expense, reducing waste, and increasing resident income. Meanwhile, government should increase the access of health care for the vulnerable population through medical assistant system.(5) It needs to implement the basic essential drug policy and promote an appropriate using of medicine. There is a strong need to sufficiently reimburse the primary medical institutions in order to reduce or eliminate the economic incentive for using drug to generate revenue through prescription.更多还原