【作者】 孙彦彦；

【导师】 樊丽明；

【作者基本信息】 山东大学 ， 财政学， 2014， 博士

【摘要】 2003年非典(传染性非典型性肺炎,SARS)的阴霾尚未完全消退,肇始于墨西哥的甲型H1N1流感又在全球范围内大规模流行。根据世界卫生组织(WHO)报告,每年全球死亡人数约5500万,其中约1/4死于传染病。2010年全世界新增疟疾病例超过2357万,死亡33万人；新增结核病例约880万,死亡145万人；新增艾滋病毒感染者270万,进而使艾滋病毒携带总人数超过3400万。由于经济全球化的发展,人和物的流动规模不断扩大、频率不断加快,使昔日的传染病转化为全球性传染病,致使传染病造成的福利损失越来越大,而控制与消除传染病变得越来越困难。据估计,1995年爆发的疯牛病使英国经济损失57.5亿美元；2003年爆发的SARS使得世界贸易、旅游和服务业损失超过300亿美元,中国和加拿大因此导致的经济损失占到本国GDP的1%；到2010年由于HIV/AIDS和疟疾所造成的劳动力损失导致撒哈拉沙漠以南的非洲中部地区(Sub-Saharan Africa)的GDP下降20%或更多；即使在传染病人数相对较少的美国,每年用于治疗的费用仍超过1200亿美元。传染病因其巨大的危害性,世界各国从未停止与之的斗争。尽管个人健康不是公共品,但健康的一个重要的外部性特征具有公共品的性质。预防一个人得传染病显然有利于与之相关的其他人,并且通过降低被传染的风险,而对其他人产生正外部效应。国与国之间也大体如此。然而,传染病控制在其效果上具有非竞争性,其供给既需要排他性的投入,如接种疫苗、干净的水等,也需要非排他性的投入,如预防知识、最佳治疗方法等。无论哪种投入都存在供给不足的情况。而全球传染病控制供给不足的最直接原因就是资金不足,那么建立有效的筹资机制是保证资金充足、稳定的关键。近年来,尽管筹资机制不断创新,从最初的双边捐赠到公私合作伙伴关系的建立,为全球传染病控制筹集了大量资金,但仍存在资金缺口,甚至出现加大的趋势。以全球疫苗免疫联盟(The Global Alliance for Vaccines and Immunisation, GAVI)为例,在1999-2008年的10年间,全球疫苗免疫联盟共收到公共和私营部门捐赠者提供的38亿美元现金和承诺,并已向符合资助标准的国家拨付27亿美元。但从2009年起至2015年,全球疫苗免疫联盟估计共需筹集资金81亿美元,其中存在的资金缺口约30亿美元。显而易见,充足的资金来源是全球传染病控制的第一步。只有有充足的资金做支撑,防治传染病的措施才能得以施展,治疗传染病的药物才能得以生产并且用于治疗,全球防治传染病的进程才‘能够不断推进。那么,要保证资金充足、稳定、持续,必须建立有效的传染病控制筹资机制。全球传染病控制的筹资机制由哪几部分构成?随着经济发展、国际贸易的加强、全球经济的一体化,传染病控制的筹资主体是如何演进的?存在哪些筹资方式和资金来源渠道?影响筹资机制的因素有哪些?全球小儿麻痹症和艾滋病控制的筹资机制是怎样的?筹资机制的绩效如何?如何优化全球传染病控制的筹资机制?基于上述问题,本文以全球公共品供给为视角,通过建立全球传染病控制筹资机制的分析框架,梳理全球传染病控制中筹资主体、筹资方式及资金来源的演变历史,分别剖析小儿麻痹症和艾滋病控制中的筹资机制,以期为全球传染病控制筹资机制的优化提供有针对性的政策建议。本文共分为7章,除第1章引言外,第2-3章是文章的分析基础,第4-7章分别是传染病控制中筹资机制的历史考察及其影响因素、典型案例及政策建议,具体包括：第1章为引言。主要包括问题提出、主要概念界定、研究框架与内容、研究方法及创新与不足等。第2章为文献综述。梳理了全球公共品的定义与分类、全球公共品的供给机制与技术、全球传染病控制的筹资机制、筹资机制的绩效评价等方面的理论与实证研究,并加以评述。第3章为全球传染病控制中筹资机制及优化的理论分析。本章主要包括四方面内容：一是全球传染病控制的阶段特征及其公共品属性,本部分将全球传染病控制分成预防阶段和治疗阶段,并分析了各阶段的特征及其公共品属性；二是全球传染控制中筹资机制的要素分析,将传染病控制筹资机制分成筹资主体、筹资方式、资金来源及激励约束机制四大要素；三是全球传染病控制筹资机制的影响因素,本文将影响因素分为经济因素和社会因素；四是全球传染病控制中筹资机制的绩效评价,设计了筹资机制绩效评价的指标体系,并介绍了测算效率的方法。第4章为全球传染病控制筹资机制的历史考察。本章首先将传染病控制中的筹资机制大体分为三个阶段,即自愿供给与政府主导阶段(20世纪50年代以前)；国际组织主导阶段(20世纪50年代—80年代)；多元化筹资阶段(20世纪80年代以来),梳理总结每个阶段筹资机制及其构成要素的基本特征；其次,分析多元化筹资阶段影响筹资机制的主要因素,计量结果表明一国的自有资金和外来资金间可能存在一定程度的替代效应。随着一国经济实力的增强,传染病防治的主导力量逐渐由国际转移到国内,发展本国经济,建立完善的传染病监测、预警、预防与控制体系是全球传染病控制的根本。第5章为全球传染病控制中的筹资机制I：小儿麻痹症例证。本章首先将小儿麻痹症的筹资机制分成疫苗使用之前阶段和疫苗使用之后阶段,分析了每个阶段的特征及筹资机制的四大要素。结果表明：疫苗使用之前,政府成为主要的筹资主体,财政拨款和慈善捐赠成为资金的主要来源。但在疫苗的开发、小儿麻痹症在工业化国家的消灭和全球共同行动阶段,筹资机制存在较为明显的差异。国际组织和慈善机构担当起领导者的角色。其次,本章对小儿麻痹症的筹资机制进行了绩效评价。结果表明：从定性角度看,GPEI需在降低筹资风险和保持资金来源的稳定性方面有所加强；从定量角度,GPEI筹资机制的运行效果较好,但应降低筹资总成本,特别是人员支出和行政管理费以提高其经济性和效率性。第6章为全球传染病控制中的筹资机制II：艾滋病例证。本章首先分析了全球艾滋病控制的阶段特征及其公共品属性；其次,分析了艾滋病控制预防阶段的筹资机制和治疗阶段的筹资机制。结果表明：与小儿麻痹症不同,全球艾滋病的控制存在两个特点：一是目前还没有研制出预防艾滋病的疫苗,因此,艾滋病的治疗费用挤占了大部分资金；二是艾滋病具有一定的区域性,这使得艾滋病筹资机制的重点在于如何激励工业化国家及相关企业进行疫苗研发,特别是针对专门用于非洲国家疫苗的研发。最后,本章对艾滋病的筹资机制进行了绩效评价。结果表明：从定性角度看,UNAIDS应在保持筹资行为的长期性、持续性,资金来源的稳定性、多样性,筹资方式的优越性方面有所强化；从定量角度看,UNAIDS筹资机制运行的效果较好,但应降低筹资总成本,特别是人员支出以提高其经济性和效率性。第7章为全球传染病控制中筹资机制的优化方向。本文优化方向的选择为降低筹资总成本、增加筹资总收入以提高筹资机制运行的绩效,其中,为了筹集更多资金应构建多层次的筹资主体、探索新的筹资方式、寻找稳定的资金来源和创新激励约束机制。而调整资金分配结构,向发展中国家分配更多的资源以增强筹资机制的公共性则是作为筹资主体的国际组织应承担的责任。本文在以下几方面尝试创新：第一,从全球公共品研究的视角,分析了全球传染病控制的筹资机制及其构成要素。结果表明：全球传染病控制由预防阶段转向治疗阶段,其公共品属性逐渐变弱,由此决定了筹资主体由单一性转为多元化,进而决定了筹资方式和资金来源也向多样化发展。以小儿麻痹症和艾滋病控制为典型案例,剖析不同技术水平下,全球传染病控制筹资机制设计的差异。本文认为两个案例筹资机制的侧重点分别在于疫苗的推广(小儿麻痹症)和疫苗的研发(艾滋病)。第二,运用面板数据模型分析了全球传染病控制筹资机制的影响因素。实证结果表明：一国传染病发病率对该国家获得官方发展援助(ODA)额有显著的正效应,而对该国的人均传染病支出影响不显著；衡量一国经济发展水平的人均实际GDP对该国获得的官方发展援助影响尽管不显著,但是与ODA呈负相关；而人均实际GDP对一国人均传染病支出却产生显著的正效应。可见,一国的自有资金和外来资金间可能存在一定程度的替代效应。随着一国经济实力的增强,传染病防治的主导力量也逐渐由国际转移到国内,发展本国经济,建立完善的传染病监测、预警、预防与控制体系是全球传染病控制的根本。第三,从筹资主体、筹资方式、资金来源和激励约束机制四方面构建了全球传染病控制筹资机制绩效评价的定性指标体系；从经济性、效率性和效果性三方面构建了筹资机制绩效评价的定量指标体系。同时,运用非参数分析法(数据包络分析)测算了GPEI和UNAIDS筹资机制的效率。结果表明：从定性角度看,GPEI需在降低筹资风险和保持资金来源的稳定性方面有所加强；UNAIDS应在保持筹资行为的长期性、持续性,资金来源的稳定性、多样性,筹资方式的优越性方面有所强化。从定量角度看,GPEI和UNAIDS筹资机制运行的效果性都较好,但应降低筹资总成本,特别是人员支出和行政管理费以提高筹资机制运行的经济性和效率性。第四,提出全球传染病控制筹资机制优化的目标不仅在于提高筹资机制运行的绩效,更应增强筹资机制的公共性。一是有计划地公开与健康相关的知识,特别是保证发展中,国家可以享受到医学技术进步带来的收益,增强筹资机制的公共性。二是在资金分配上,国际组织应将有限的资源尽量向发展中国家倾斜,帮助发展中国家建立能够发放疫苗、管理治疗以及监督疾病和死亡的国内卫生基础设施,提高发展中国家进行传染病控制的能力。更多还原

【Abstract】 The SARS (severe acute respiratory pneumonia, SARS) haze in2003has not completely subsided, H1N1influenza in Mexico spread worldwide. About55million people die each year in the world according to the report of World Health Organization (WHO), a quarter of them die of infectious diseases. The new cases of malaria worldwide in2010is over23.57million and33million people died; approximately8.8million new TB cases and1.45million people died;2.7million additional people living with HIV, and thus bring the total number of HIV more than34million. As development of economic globalization, scale of people and things mobility is expanding, and frequency is speeding up, which makes infectious diseases globalization. Welfare losses caused by infectious diseases are increasing while it’s become more difficult to control and eliminate infectious diseases. It is estimated that the outbreak of mad cow disease in1995caused a loss of＄5.75billion of the UK economy. In2003, the outbreak of SARS resulted in huge economy loss of30billion U.S. dollars for the global trade, tourism and services industry. Especially, in China and Canada, the enormous economic losses caused by SARS accounted for1%of their GDP. The GDP of sub-Saharan Africa and Central regions had decreased by20%or more by the year of2010, which caused by the loss of manpower due to the HIV/AIDS and Malaria. The annual cost for the treatment is more than120billion U.S. dollars in America even if the number of suffers is small relatively.The whole world has never stopped the fight against infectious diseases because their serious consequences. Although personal health is not public goods, but an important external nature feature of health is public goods. Prevention of personal infectious diseases was apparently in favor of other people associated, and by reducing the risk of infection generates positive externalities on others. The same is true among nations. However, its effect on infectious disease control is non-competitive, it requires both exclusive supply inputs, such as vaccination and clean water, etc., and also need to put non-exclusive investment, such as prevention knowledge, the best treatment methods, etc. Both investment supplies are insufficient. The most direct cause of global infectious disease control supply shortage is the lack of funds; the establishment of effective financing mechanisms is the key to guarantee sufficient funds and stability. In recent years, despite the raising mechanism is innovative, from the initial bilateral donors to the public-private partnership established, financing a lot of money for global infectious disease control. But there is still a funding gap and presents increasing trend. To the Global Alliance for Vaccines and Immunization (The Global Alliance for Vaccines and Immunizations, GAVI), for example, in the10years between1999-2008, the Global Alliance for Vaccines and Immunization has received public and private sector＄3.8billion in cash and commitments of donors, and State funding has been made to meet the standards financed＄2.7billion. But from2009to2015, the Global Alliance for Vaccines and Immunization need total funding＄8.1billion, of which the existence of a funding gap of about＄3billion. Obviously, adequate funding is the first step in global infectious disease control. Only with sufficient fund, measures of infectious disease prevention and control can be in order, and then infectious diseases drugs can be produced and used in the treatment, the prevention and control of infectious diseases processes can to be continued. We must establish an effective disease control funding mechanism to ensure adequate stable and sustainable funding. Which several parts are the financing mechanisms composed of? With economic development, strengthening of international trade and integration, what is the evolution of the main infectious disease control? What are the financing and funding sources? What are the factors of affecting the funding mechanisms? What are the Global Polio and AIDS controlling funding mechanisms? How are funding mechanisms? How to optimize the financing mechanism for global infectious disease control?Based on the above issues, the perspective in this paper is the global public goods supply. Through the establishment of global funding mechanism analysis framework, combing the financing subjects, the evolution history of financing and sources of funds, analyzing financing mechanisms of Polio and AIDS in order to optimize the global infectious disease control funding mechanisms and providing policy recommendations.The paper is divided into seven chapters, Chapter1is an introduction and Chapter2-3is the basis of an analysis of the article. The Chapters4to7are historical research, influencing factors, typical cases and policy recommendations in the funding mechanism in the control of infectious diseases. For particular description:Chapter1is an introduction. It mainly includes putting forward the topic, the definition of the main concepts, research framework and content, research methods, innovation and deficiencies, etc.Chapter2is a literature review. It combs theoretical and empirical studies about the definition and classification of global public goods, supply of global public goods financing and financing in communicable disease control. It also makes a brief review of them.Chapter3analyzes the theory of infectious disease control and optimizing in the funding mechanisms. This chapter includes four parts:Firstly, phase characteristics of global infectious disease control and public goods property, the article divides phase characteristics into prevention phase and treatment phase, and analyses phase characteristics and public goods property. Secondly, essential factors analysis of financing mechanisms in the global infectious disease control, the article divides the financing mechanisms into financing subjects, financing methods, funding sources and incentive mechanism. Thirdly, global infectious disease control financing mechanism influencing factors, introducing economic and social influencing factors. Fourthly, performance evaluation of global infectious disease control financing mechanism, designing index system of financing mechanism performance evaluation and introducing calculating efficiency methods.Chapter4refers to the historical survey of the global financing mechanisms for infectious disease control. In the beginning of this chapter, financing mechanisms’ implementation is divided into three phases in principle-voluntary supply and government leading phase (before1950s), international organization leading phase (1950s-80s), and diversified financing phase (since1980s), in each of which the basic characteristics of financing mechanisms and their elements are summarized. Then the main factors affecting financing mechanisms in the diversified financing phase are analyzed. The econometric result shows that there may be a degree of substitution effect between its own funds and foreign funds in a country. With a country’s economic boost, the leading forces in the fight against infectious diseases shift gradually from international to domestic. The development of national economy and the establishment of a perfect infectious disease surveillance, early warning, prevention and control system are the key measures of controlling global infectious diseases.Chapter5presents the first financing mechanism of the global infectious disease control-an example of polio. Firstly, polio financing mechanism is divided into two phases-before and after the use of the vaccines. Also the characteristics of each phase and four elements of financing mechanisms are presented. The result shows government is the major financer before the use of the vaccines and fiscal appropriation and charity donations become the main sources of funds. But there are obvious differences in financing mechanisms, in the phase of vaccine’s development, industrialized countries’ eradication of polio, and global cooperation. International organizations and charities take on the leadership role. Secondly, the chapter conducts a performance evaluation on financing mechanisms. The result indicates that from a qualitative point of view, GPEI needs to be strengthened in reducing the risk of financing and maintaining the stability of funding sources. And from a quantitative point of view, GPEI financing mechanism works well, except the necessity to reduce the total financing cost, especially personnel expenses and administrative expenses, for the purpose of improving its economy and efficiency.Chapter6presents the second financing mechanism of the global infectious disease control-an example of AIDS. In the beginning, the Chapter analyzes the phase characteristics of the global AIDS control and its characteristics of public goods. Besides, it analyzes the funding mechanisms of AIDS control and prevention phase, as well as its treatment phase. The result reveals that unlike polio, there are two features of global AIDS control. First, a vaccine to prevent AIDS has not been developed, so AIDS treatment costs account for the majority of funds. Secondly, AIDS is somewhat regional, making AIDS funding mechanisms focus on how to motivate industrialized countries and relevant companies to develop vaccines, especially the development of vaccines specifically for African countries. Finally, a performance evaluation on AIDS financing mechanisms is made. The result indicates that from a qualitative point of view, UNAIDS needs to keep financing activities long-term and sustainable, maintain stable and diversified funds sources, and enhance the superiority of ways to finance. And from a quantitative point of view, UNAIDS financing mechanism works well, except the necessity to reduce the total financing cost, especially personnel expenses, for the purpose of improving its economy and efficiency.Chapter7is about the optimal directions of financing mechanisms in the global infectious diseases control. The optimizing direction is to reducing the total financing cost and raising the total financing income which aims at improving the operating performance of financing mechanisms. In order to raise more income, we should construct multi-level financers, explore new ways of financing, find stable sources of funding,and innovate in incentive and restraint mechanisms. At the same time, enhance the public nature of financing mechanisms by adjusting the allocation structure of the funds and allocating more resource to developing countries which is the responsibility of international organizations.This paper tries to innovate in the following aspects:Firstly, from the perspective of global public goods research, this paper analyzes the financing mechanisms and their elements of global infectious disease control. The result shows when global infectious diseases phases shift from the prevention phase shift to the treatment phase, its public goods characteristic is weakened, which changes the structure of financers from single to diversity. Taking polio and AIDS as examples, the paper analyzes the differences in financing mechanisms designed for global infectious diseases control, under different skill levels. This paper argues that the focuses on financing mechanisms in the two cases are promotion of vaccines (polio) and the research and development of vaccines (AIDS), respectively. Secondly, this paper uses the panel data model to analyze the factors affecting financing mechanisms for global infectious diseases control. Empirical result indicates the incidence of infectious diseases in a country has a significant amount of positive effects with its access to official development assistance (ODA), while the effect on the country’s spending on infectious diseases per capita is not significant. Real GDP per capita, measuring the level of a country’s economic development, is negatively correlated with ODA, although not significant. And Real GDP per capita is significantly positively correlated with per capita expenditure on infectious diseases of this country. Therefore, Substitution effect may exist between a country’s own funds and foreign funds in a degree. With the economy of a country boosting, the leading forces in the fight against infectious diseases shift gradually from international to domestic. The development of national economy and the establishment of a perfect infectious disease surveillance, early warning, prevention and control system are the key measures of controlling global infectious diseases.Thirdly, this paper establishes a qualitative index system of the performance evaluation of financing mechanisms for global infectious diseases control, including financers, way of financing, sources of funds and incentive and restraint mechanisms. Meanwhile, it estimates the efficiency of GPEI and UNAIDS financing mechanisms with non-parametric analysis (data envelopment analysis). The result shows that from a qualitative point of view, GPEI needs to work on reducing the risk of financing and maintaining the stability of funding sources and UNAIDS needs to keep financing activities long-term and sustainable, maintain stable and diversified funds sources, and enhance the superiority of ways to finance. From a quantitative point of view, GPEI and UNAIDS financing mechanisms work well, but they should reduce the total financing cost, especially personnel expenses and administrative expenses, for the purpose of improving its economy and efficiency.Fourthly, the purpose of optimizing financing mechanisms for global infectious diseases control is not only to improve the operation performance of financing mechanisms, but also to strengthen their public nature. Firstly, popularize health knowledge systematically, and especially ensure that developing countries can enjoy the interests brought by the advances in medical technology. And enhance the public nature of financing mechanisms. Secondly, as for the allocation of funds, international organizations should try to tilt the limited resources to developing countries, to help developing countries build domestic health infrastructure for delivering vaccines managing the treatment and supervising diseases and deaths, and improve their ability to control infectious diseases.更多还原