【作者】 杨学来；

【导师】 徐凌忠；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2013， 博士

【副题名】S省卫生筹资案例研究

【摘要】 研究背景卫生系统是满足人民群众医疗卫生需求,实现公平和社会团结稳定的重要部门。根据世界卫生组织提出的卫生系统框架,卫生系统发挥卫生筹资、要素生产、服务提供和管理等职能,从而实现健康、筹资风险保护(避免因病致贫和灾难性卫生支出)和反应性三个目标。建国以后,我国在计划经济时期迅速建立卫生系统,以较低投入实现了医疗卫生服务覆盖全民,成为世界卫生组织推崇的典范。当时卫生系统实现了较高的公平性,但存在服务提供效率低,缺医少药等问题。改革开放以后,卫生系统借鉴其他经济领域改革的做法,引入新的激励机制,医疗卫生资源快速增加,服务提供能力和效率明显提高,但随之而来的问题是卫生筹资过度依赖个人卫生支出,居民疾病经济负担沉重,“看病贵”问题日益突出,这实际上是卫生筹资公平问题的集中表现。世界卫生组织《2000年世界卫生报告》对191个成员国卫生系统绩效进行评估排名,我国整体绩效位于第61位,但对卫生系统筹资公平性指数评估排名中,我国名列第188位,倒数第4位。这一评估结果在我国产生强烈反响,使得卫生筹资公平性问题成为卫生系统内外关注的一个焦点。此外,卫生筹资公平也对其他社会公平领域产生了较大影响。改革开放以来,我国对农村地区的扶贫工作取得了巨大成就,我国农村贫困人口由1978年的2.5亿人减少到了2002年的2820万人,绝对贫困发生率也从以前的30.7%下降到3.0%,但新时期我国的扶贫任务仍然十分艰巨,脱贫人口又重新返回贫困状态的现象比较突出,其中“因病返贫”是重要原因之一。提高卫生系统公平是我国未来很长一段时间需要实现的目标,卫生服务公平性问题是我国深化卫生改革中关注的焦点问题之一。卫生公平的实现需要卫生系统各模块的共同作用,其中卫生筹资是卫生系统的核心模块,负责卫生资金的筹集、分配和使用,对卫生系统其他模块如服务提供、资源生产、管理等模块功能的实现起着基础性作用,并与卫生系统目标之一的筹资风险保护直接相关。卫生筹资系统的公平性是决定卫生公平的重要影响因素,因此在世界卫生组织《2000年世界卫生报告》中将筹资风险保护作为卫生系统的三个主要目标之一,并进行评价和排序。因此卫生筹资公平性已经得到政府以及社会各界的广泛重视,并且已经成为社会学、医学、经济学等诸多学科的研究热点；同时也是社会经济生活中一个重大理论与现实问题。党中央提出到2020年全面建成小康社会奋斗目标的新要求,并提出建立社会公平保障机制,卫生公平特别是卫生筹资公平是核心内容之一,目前我国处于医药卫生体制改革深入开展的特殊阶段,从卫生筹资系统的角度对卫生筹资公平问题进行研究具有重要的理论和现实意义。研究目的基于卫生筹资系统功能从卫生资金筹集公平、分配受益公平和筹资风险保护的维度研究S省卫生筹资公平性状况,并分析卫生资金筹集公平和受益公平与卫生筹资风险保护的关系,为以公平为导向的医药卫生体制改革提供政策建议。资料与研究方法本研究采用S省2008年家庭服务调查数据,样本总量为3958户,12973人,其中男性占49.43%,女性占50.57%,数据具有全省代表性。测算和分析中涉及的变量包括家庭人口数和年龄结构、家庭收入、消费性支出、医疗服务利用、自付医药费用等。本次调查采用多阶段分层整群系统随机抽样方法,基本抽样单位为乡镇和街道,以保证所调查样本的代表性。分别抽取30个乡镇和30个街道,每个乡镇和街道分别抽2个行政村和2个居委会、每个村和居委会随机抽33户,调查涉及全省14个市(州),36个县(区)。本研究从卫生筹资系统功能的角度出发研究卫生筹资公平性,主要思路是首先根据卫生筹资环节和功能确定卫生筹资公平性的分析维度,提出卫生筹资公平性分析框架。然后针对各个筹资维度选择量化分析方法,卫生资金筹集公平可以从垂直公平角度测量,采用累进性分析方法；资金分配受益公平可以采取受益归属分析方法,分析政府补助受益的公平性；筹资风险保护可以通过灾难性卫生支出和OOP致贫分析两种方法进行测量。并利用基于家庭的卫生服务调查数据进行测量和分析,最后利用不同筹资公平分析维度之间的关系分析筹资风险保护的变化,并对未来提高卫生筹资公平性提出政策建议。主要研究结果1.根据卫生筹资系统的功能和筹资环节,可以将卫生筹资公平性分为三个维度：卫生资金筹集公平、卫生资金分配受益公平和卫生筹资风险保护。其中,资金筹集公平和分配受益公平属于卫生系统的过程指标,而卫生筹资风险保护则属于卫生系统的最终目标,卫生筹资风险保护水平受卫生资金筹集和受益公平性的直接影响。2.S省卫生资金累进性结果显示,2008年S省卫生筹资以政府卫生支出(38.11%)和个人卫生支出(37.23%)为主。卫生筹资整体的Kakwani指数为0.046,基本接近等比,未呈现明显的累进性,不同经济水平人群卫生资金筹集与收入水平等比,没有体现高收入人群多出钱的垂直公平和“劫富济贫”的特点。在不同筹资渠道中,政府税收筹资接近等比,未体现明显的筹资公平和再分配作用,其中直接税筹资累进程度较高,间接税略为累退。社会医疗保险为累进,主要原因是社会医疗保险覆盖部分人群以及不同保险之间筹资和报销差异较大,实际上反映了更深层面的不公平。3.S省政府卫生投入受益公平性结果显示,2008年政府医疗总补助人群受益集中指数为0.289,较富裕人群获得补助更多,补助向富裕人群倾斜。其中住院补助受益公平性远低于门诊补助,2008年S省门诊医疗补助集中指数为0.045,接近等比,住院补助集中指数为0.375,更多的向较富裕人群集中。农村和城市居民总补助受益公平性与全省一致,受益公平水平均比较低,其中城市居民补助受益向富裕人群倾斜的程度高于农村,集中指数分别为0.319和0.229。4.S省卫生筹资风险保护水平不佳。从OOP致贫看,2008年按照2.15美元每人每天国际贫困线标准,OOP致贫率为8.38%,即有8.38%的居民因为看病就医花费陷入贫困,其中农村居民OOP致贫程度高于城市居民,农村居民OOP致贫率和贫困差距均远高于城市居民。从灾难性卫生支出方面看,按照40%的标准S省灾难性卫生支出发生率高达17.84%,即有17.84%的家庭其卫生花费占家庭非食品支出的比例超过40%,对家庭正常消费结构产生严重影响,灾难性卫生支出平均差距为2.88%,相对差距为16.65%。其中农村和城市居民灾难性卫生支出发生率比较接近,城市略高于农村。5.不同筹资公平性之间存在相互作用关系。S省卫生资金筹集公平和受益公平对筹资风险保护产生较大影响。总体上看,S省卫生资金筹集没有体现垂直公平,未能实现“劫富济贫”的作用,特别是政府税收筹资缺乏累进性,而保险筹资由于覆盖人群范围和保险分散化,虽然表现为累进但实质上反映更深层次的筹资不公平；在资金分配受益环节,政府卫生投入受益没有向低收入人群倾斜,反而是较富裕人群补助受益更多。由于在资金筹集和受益公平性程度不高,没有较好实现筹资风险保护和社会再分配作用,直接导致S省卫生筹资风险保护水平较低。同时S省资金受益公平又受到资金筹集公平和筹资风险保护的影响,S省资金筹资公平水平和筹资风险保护水平决定了居民医疗卫生服务利用在很大程度上受到居民自身支付能力的影响,低收入人群受到支付能力的制约服务利用水平较低,而高收入人群则利用了较多的医疗卫生服务,导致更多的从政府补助中受益。政策建议1.建立稳定的政府和社会卫生投入机制,建立公共筹资主导的卫生筹资系统。2.发挥税收资金再分配调节作用,提高政府卫生资金筹集的累进性。3.缩小不同社会医疗保险之间的受益差距和统筹范围,在此基础上实现资金筹集的累进性。4.加强政府补助的目标针对性,提高资金受益的公平性。5.建立针对低收入人群的费用减免机制和医疗救助制度。创新性与不足与以往研究相比,本研究有以下创新之处：(1)本研究以卫生筹资系统功能为基础,从卫生资金筹集、分配受益和风险保护等层面提出了卫生筹资公平性分析框架体系和方法,改变了以往研究主要集中于某一角度,不同筹资公平方法之间缺少理论基础和体系联系的状况。(2)本研究基于卫生系统筹资公平性框架体系和方法,在同一框架体系下系统比较不同卫生筹资维度的公平性情况,这在全国尚属首次。(3)本研究根据不同筹资公平维度之间的关系,系统分析筹资公平变化的内在联系和原因,改变了以往研究均是就某一方面公平进行分析,缺少不同公平维度结合分析的状况。本研究存在以下不足：(1)各种维度的卫生筹资公平性分析主要围绕2008年的数据展开,如果多收集几个年度的数据进行前后对比,通过时间序列分析将会得出筹资公平性的变化情况。(2)本研究对卫生筹资公平性的分析没有与居民的健康状况等指标结合起来分析,如果引入健康状况等指标将会发现筹资公平与其他公平性之间的联系。更多还原

【Abstract】 BackgroundHealth system is to meet the health care needs of the people, the method to achieve fairness and social unity and stability. According to the health system framework raised by World Health Organization, health systems have the functions of Health Financing, factor productivity, service delivery and management etc, in order to achieve the three goals of health, financing risk protection and reactivity. After the founding of our country in the planned economy period, the rapid establishment of the health system, with lower investment to achieve universal coverage of health services, became respected model of the World Health Organization. Then health system achieved a high fairness, but there was a low efficiency of service delivery, lack of medicine problems. After the reform and opening up, learn from other economic sectors health system reform, introduce new incentives, a rapid increase in medical and health resources, service delivery capacity and efficiency improved significantly, but the ensuing transition since the problem was personal health expenditure, residents disease negative economic heavy,"expensive" problems have become increasingly prominent, which is actually a concentrated expression of Health financing fairness.In the World Health Organization’s " World Health Report2000", the191member states on the achievements and performance of health systems assessment rankings, our country was located in the first61, but in the health system financing assess fairness index rankings, our country ranked No.188, that was the penultimate4. The results of this assessment had strong repercussions in our country, making the fairness of health services to become a focus of attention within and outside the health system. In addition, Fairness of health financing had a great impact to other social areas. Since reform and opening up, China’s poverty alleviation work in rural areas had made great achievements, and China’s rural poor population of250million people in1978had reduced to28.2million in2002, the incidence of absolute poverty from the previous30.7%to3.0%, but China’s poverty alleviation task of the new era is still arduous, poverty population returning poor situation again is a very prominent phenomenon, and " due to illness " is one important reason. Improving health system fairness is China’s future target for a long time. Fairness of health services is one of the focus issues to deepen health reform.The realization of health equity requires the joint action of each module in the health system, and health financing is the core module of the health system, health fund raising, distribution and use is closely related to each other, and play a fundamental role in the implementation of other modules function, such as service providing, resource production, management etc, and directly related to the health system objectives in particular with financing risk protection. Health financing system is the important factor to determine the fairness of health equity, so the World Health Organization regard the health system financing risk protection as one of the three main objectives in "World Health Report2000", and to evaluate and sort it. Therefore, the government and the community have been extensive attention to the fairness of health financing, which has become not only the research focus of sociology, medicine, economics and many other disciplines; but also a major theoretical and practical issues of the social and economic life.Our country has proposed the new goal of building a moderately prosperous society in the2020, and proposed the establishment of social equity security mechanism, health equity especially the fairness of health financing is a core element, China’s medical and health system reform is in the special stage of deepen develop, the research of the fairness from the perspective of the health financing system has important theoretical and practical significance.ObjectivesBased on health financing system functions to research the health financing fairness conditions of S province from the dimension of Health funding fairness, equitable distribution of benefits and financing risk protection, and to analyze the relationship of health funding fairness, equitable distribution of benefits and financing risk protection, in order to provide policy recommendations for the equity-oriented medical and health system reform.MethodsIn this study, Family Services survey data of S Province in2008was used, there were a total of3958samples and12,973people, among Which males accounted for49.43%, females accounted for50.57percent, Data could represent the province. Variables involved in measurement and analysis included family size and age structure, household income, consumption expenditure, health services utilization, OOP for medical service.The survey used a multi-stage stratified cluster random sampling system, and basic sampling unit were the towns and streets in order to ensure the representative of the survey samples,30towns and30streets were extracted, and every town and street were pumping two administrative villages and two neighborhoods, and each village and neighborhood random33samples. The survey involved the province’s14municipalities (state),36counties (district).In this study, we will research health financing fairness from the perspective of health financing system functions, the main idea is to determine the analysis dimensions of the fairness of health financing according to health financing aspects and functions firstly, and to propose analytical framework of the fairness of health financing, and then select the quantitative analytical methods for each funding dimension, using progressive methods to measure the vertical fairness of health funding; using Benefit Incidence Analysis Method to analyze the fairness of government subsidies benefit; funding risk protection can be measured by catastrophic health expenditures and OOP poverty analysis. And measurement and analysis is going with the data of Family Health Services Survey, the final analysis is the change of financing risk protection by using the relationship between different dimensions of the fairness of health financing, and to raise policy recommendations to improve the fairness of health financing in the future.Main Results1. According to functions and aspects of health financing system, fairness of health financing can be divided into three dimensions:health funding fairness, fairness of the allocation of funds to benefit health and risk protection. Among them, the health financing risk protection is one of the ultimate goals of the health system, health funding fairness and fairness of the allocation of funds to benefit health are process indicators of the health system, and the level of health financing risk protection is directly affected by health funding fairness and fairness of the allocation of funds to benefit.2. S provincial health funding progressive results show that in2008Government health expenditure (38.11%) and personal health expenditures (37.23%) were the main part of S provincial health funding. Health financing overall Kakwani index of0.046, was close to geometric not showed significant progressive, the health financing and the income of populations of different economic levels was close to geometric, did not reflect the vertical fairness that high-income people pay more and "Robin Hood "characteristics. In different sources of funding, the government revenue funding nearly geometric, did not reflect significant role in the financing of equity and redistribution, in which direct taxes financing had a higher degree of progressivity, but indirect taxes was slightly regressive. Progressive social health insurance, mainly because part of the population covered by social health insurance as well as financing and reimbursement between different insurers were quite different, actually reflected a deeper level of unfairness.3. S provincial fairness of government health spending to benefit showed that in2008the centralized index of the total government health subsidy benefit was0.289, more than the rich people get grants and subsidies incline to rich people. Hospitalization subsidy benefit was much lower than the fairness of outpatient benefits, in2008the concentration index of outpatient benefit of S province was0.045, close to the geometric, and the concentration index of hospitalization subsidies was0.375, more focused to the more affluent crowd. The fairness benefit of total subsidy of rural and urban residents was consistent with the province, the levels of fairness benefit were very low, in which the degree of tilt to the rich of urban residents benefit from subsidies was higher than rural, Concentration index were0.319and0.229.4. Level of protection of health financing risk was poor in S province. In2008in accordance with the international poverty line of$2.15per person per day, poverty rate of OOP was8.38%, that is,8.38%residents of S province got into poverty because of medical treatment costs, the situation of rural residents is more serious than urban residents. From catastrophic health expenditure side, according to the standard of40%the rate of occurrence of catastrophic health expenditures was17.84%, ie17.84%of the families’ health spending in total household non-food expenditure accounted for more than40%,and the normal consumption structure would be serious influenced, the average gap of catastrophic health expenditures was2.88%and the relative gap was16.65%, incidence of catastrophic health expenditure was relatively close between rural and urban residents, and the urban was slightly higher than the rural.5. There are interactive relationships among the different financing fairness. Health funding fairness and fairness benefit has a great impact on financing risk protection in S province. Overall, S provincial health funding did not reflect vertical equity, failed to achieve "Robin Hood" role, especially the government funding taxation lack of progressivity, while the financing of insurance although looked as progressive but in fact reflected a deeper unfair of Financing because of the population covered by the scope of the insurance financing and decentralized. In the allocation of funds to benefit aspects, the government health spending to benefit did not incline to low-income people, on the contrary to the more affluent crowd. Since the fairness of funding and benefit level was not high, the function of funding risk protection and social redistribution did not work well, which led to a low level of health financing risk protection in S province. Meanwhile fairness of the allocation of funds to benefit health was influenced by health funding fairness and financing risk protection in S provincial, the level of health funding fairness and financing risk protection determined the residents use of health services, health services of low-income people was constrained by the ability to pay, while high-income people would use more health services, resulting in more benefit from government subsidies.Policy Recommendations1. To establish a stable government and society health input mechanism, to establish health financing system leading by public financing.2. To play a role in regulating the redistribution of tax, increase the progressivity of government health funding.3. To narrow the benefit gaps and coordinating range of different social health insurance, and on this basis, to achieve the progressive financing.4. To strengthen government subsidies to targeted to improve the fairness of the benefit funds.5. To establish fee waivers and medical aid system for low-income populations.Innovations and limitationsThe innovations of this study:(1)Based on health financing system functions this study proposes analytical framework and methods for fairness of health financing, from the aspects of health fund raising, distribution and benefit and risk protection, and changing the situation of the past research which has focused on a certain angle, and different methods of financing lack of theoretical foundation and system Contact.(2)This study is based on fair health financing framework and methodology, to compare different dimensions of health financing fairness in the same framework, and this is the first time in the country. (3)In this study, according to the relationship of different dimensions of equity financing, to analysis the internal relations and causes of the changes of fairness of health financing, changing the previous condition of studies were carried out on a particular aspect of fair analysis, lack of combined analysis of different dimensions.The limitations of this study:(1)Fairness analysis of various dimensions mainly around2008data expand, If more than a few years of data is collected for the use of before and after comparison, Through time series analysis will draw funding fairness changes。(2)This study analyzes the fairness of health financing without combination of other indicators,for example the health status of the residents. If health status indicators are introduced, we will find links between different fairness.更多还原