【作者】 成刚；

【导师】 孟庆跃；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2008， 博士

【摘要】 背景艾滋病的流行已成为一个严重影响人类健康和全球社会经济发展的公共卫生危机问题,艾滋病对人类健康已经造成的危害和潜在的威胁是史无前例的。联合国在其发布的《人类发展报告2005》中断言:“艾滋病造成了人类发展史上最为严重的倒退”。世界各国艾滋病流行态势及防治经验表明,预防和控制艾滋病是一项刻不容缓、复杂而长期的艰巨任务。与艾滋病防治工作所需要的资金数量相比,资金不足是一个全球性的问题。根据联合国艾滋病规划署(UNAIDS)的测算,目前全球艾滋病防治国际合作资金每年约有100亿美元,而实际需要则高达每年200—230亿美元。中国政府高度重视艾滋病防治工作,不断加大艾滋病预防和控制力度,资金投入也迅速增长。2006年1月29日,国务院颁布《艾滋病防治条例》。《条例》明确了“以政府投入为主,分级承担、多渠道筹资”的筹资机制,规定“县级以上地方人民政府按照本级政府的职责,负责艾滋病预防、控制、监督工作所需资金”,“中央财政对在艾滋病流行严重地区和贫困地区实施的艾滋病防治重大项目给予补助”,“国家鼓励和支持开展艾滋病防治工作的国际合作与交流”。为此,中央财政设立了艾滋病防治专项资金,并且已经列入年度中央财政预算。该资金主要用于中央有关部门开展防治工作和对重点疫区和经济困难地区进行补助。从艾滋病防治资金来源构成看,目前我国艾滋病防治资金的主要来源为政府财政投入。它具有资金数量大、稳定性强、可持续性强的特点,对整个艾滋病防治工作的开展发挥着主导作用。此外,国际合作项目资金数量仅次于政府投入,其来源相对稳定,对艾滋病防治工作起着重要的补充作用。近年来,随着国内艾滋病防治资金的迅速增长,对艾滋病筹资问题的学术关注也逐渐增强。综合国内关于艾滋病筹资的研究结果,可以做出以下结论:1)目前各级地方政府尚未完全承担起艾滋病防治工作筹资的职责;2)中央财政转移支付资金在各省的分配体现了补助“艾滋病流行严重地区”的原则,但是没有体现补助“贫困地区”的原则。由于受到数据可得性的影响,已有研究内容还比较局限,并且研究对象局限在国家或省级层面。但是艾滋病各项防治工作的落实主要是在县级,而已有的研究和结论主要是在国家级和省间层面上做出的,目前尚缺少在省内、特别是县级层面点对艾滋病筹资问题的研究,而这样的研究对于评价艾滋病筹资政策的执行情况和指导决策具有重要的应用价值。另外,艾滋病防治工作的投入产出情况、艾滋病项目资金的实际使用状况和效率是决策者关心的一个重要问题,目前国内文献还没有提供这样的研究信息。本研究的主要目的是通过分析我国艾滋病防治资金的筹集、分配和利用状况,揭示县级政府在艾滋病筹资中的职责履行情况,中央财政资金在县级分配的合理性,以及影响艾滋病资金利用效率的因素,为我国艾滋病筹资决策和项目管理提供参考信息。研究方法本研究以定量研究为主并结合案例分析。根据研究目的,分别选取并收集四川省181个县(市、区)2004—2006连续三年的疫情、资金筹集和分配数据,中原七省(安徽、河北、河南、山东、山西和陕西省)72个艾滋病项目县2005-2007连续三年的疫情、资金使用及产出数据作为研究对象。数据的分析方法包括描述性统计分析、方差分析、Probit回归模型和线性回归模型。由于本研究全部数据均为面板数据结构(横断面时间序列数据),面板数据在进行统计分析时需要进行特殊的处理,这包括方差分析进行重复测量因素的校正,回归分析根据分析目的区分为组间效应模型和组内效应模型,组内效应模型又划分为固定效应模型和随机效应模型。数据的描述性统计分析和统计图表主要使用MS Excel软件,统计模型分析使用Stata 10软件。研究结果县级财政设立艾滋病专项资金的比例很低。2004年四川省181个县(县级市、区)中仅有16个县级财政(8.84%)设立了艾滋病专项资金,投入总额为48万元,投入最高者为10万元,最低者为0.2万元;2005年全省仅有28个县级财政(15.47%)设立了艾滋病专项资金,投入总额为157万元,投入最高者为20万元,最低者为0.3万元。县级财政是否设立艾滋病专项资金及资金的数量与HIV感染者人数和人均GDP没有关系。人口数对县级财政资金的影响作用具有统计学意义,人口数每增加10万,县级财政资金数量平均增加910元,其实际意义不大。并且人口数对县级财政资金数量的解释作用仅为4.5%。HIV感染者人数、人口数和人均GDP三个变量对中央财政资金在县级的分配数量的影响作用均具有统计学意义,但是资金数量主要受疫情因素的影响,其它两个变量的影响作用较小。HIV感染者人数越多、人口数越多、人均GDP越高,县级获得中央财政资金的数量越多。中央财政资金在县级的配置体现了“重点支持高疫情地区”的原则,但没有体现“重点支持贫困地区”的原则。2005年—2007年,中原七省艾滋病项目活动资金执行率逐年上升,2007年平均资金执行率达98.36%。多部门合作资金占总活动资金的比例逐年增加,2007年已接近总资金数量的一半。参与艾滋病防治工作的非政府组织主要包括工会、共青团、妇联、红十字会、计划生育委员会、相关学会和协会、学术机构(高校和研究院/所)、草根组织等。每项活动支持的资金额度从千元到数十万元不等,平均为1.5万元,学术机构和国际组织资金相对较高,草根组织资金较少。VCT单位成本在各省之间和各周期间存在明显的差异,最高时为356.65元,最低时为30.25元。从项目第2周期开始,随着项目进展,各省的VCT单位成本均呈现逐渐下降的趋势。周期1各省平均VCT单位成本为100.24元,至周期6下降为61.63元,下降了38.52%。VCT单位成本随着项目累计资金投入数量的增长而下降,回归模型结果表明县均累计资金数量每增加10万元,VCT单位成本降低30%。ART单位成本在各省和各周期间存在巨大差异,最低时为51.84元,最高时达到8601.06元。与VCT单位成本的变化趋势相反,随着项目进展,各省的ART单位成本总体上呈现逐渐上升的趋势。周期1各省平均ART单位成本为193.55元,至周期6上升为450.92元,上升了3.82倍。ART单位成本随着项目累计资金投入数量的增长而上升,回归模型结果表明县均累计资金数量每增加10万元,ART单位成本上升81%。中原七省的艾滋病防治项目预防干预工作取得了明显的效果。2007年与2005年相比,大众人群艾滋病知识知晓率提高了31个百分点,FSW艾滋病知识知晓率提高了32个百分点,FSW最近一次商业性行为安全套使用率提高了13个百分点。结论与政策建议市、县级地方财政没有承担起艾滋病筹资的应有职责。总体上讲,县级财政对艾滋病防治工作的投入严重不足,没有承担起艾滋病防治应有的筹资责任。建议采取有效措施使地方政府承担起艾滋病筹资的应有的职责。地方财政特别是县级财政对艾滋病防治资金的投入数量应该明文确定并予以量化。地方财政的投入应与地方政府的财政能力相适应,经济发达地方投入较多的资金,经济欠发达地方可以投入较少的资金。经济欠发达地区不足部分可通过中央财政和省财政的转移支付补足。中央财政资金在县级的配置体现了重点支援艾滋病流行严重地区的原则,但没有体现出对经济欠发达地区的重点支援。建议明确并公开上级财政资金分配方案,充分发挥财政转移支付职能。中央转移支付资金需要加大对欠发达地区转移支付的力度,使经济欠发达地区的防治资金得到必要的保证。中央财政和省财政资金在进行区域配置时应充分发挥财政转移支付职能,这不仅能起到平衡各地区艾滋病防治资金的作用,同时还可以促使地方政府发挥其在艾滋病防治筹资中的职能,调动地方政府对艾滋病防治工作的积极性和责任意识。在艾滋病项目执行过程中,应加强对各工作领域资金使用效率的测算并对其影响因素进行研究。根据测算和研究结果,适时调整资金在项目地区和工作领域的分配,以提高资金的使用效率。以VCT和ART为例,本文研究结果表明,VCT资金的使用效率随着项目进展和资金的持续投入而逐渐提高,从效率角度考虑,应保障VCT工作的持续投入。但是,由于艾滋病项目一般为持续数年的短期项目,在项目结束后,资金的持续性如何保证是决策部门应该考虑的问题;相反,ART资金的使用效率随着项目进展而逐渐下降,从效率的角度考虑,项目管理部门应根据对ART效率的测算数据,确定一个合理的效率界限值,对ART资金使用效率低于界限值的地区的ART资金做出适当的调整,将其ART资金调整为其它领域资金,或将其ART资金调整到其它效率高的地区使用。项目资金调整的前提是资金的可调整性,目前艾滋病项目资金的调整,包括资金在各工作领域的调整和在各项目地区的调整,均需要繁琐的审批手续,实际执行难度很大,这是项目管理机构和出资方应该关注的一个问题。更多还原

【Abstract】 BACKGROUNDThe epidemic of HIV/AIDS has been a great public health crisis, and it has become one of the make-or-break forces of this century, as measured by its actual impact and potential threat to the survival and wellbeing of people worldwide. The global impact of AIDS has already been so devastating that the United Nations’ Human Development Report 2005 concluded that "the HIV/AIDS pandemic has inflicted the single greatest reversal in human development. Compared to the amount of fund needed for HIV/AIDS prevention and treatment, inadequate funding is a global problem. According to UNAIDS estimates, the current global fund for AIDS prevention and control of international cooperation is about 10 billion US dollars every year while the actual requirements will be up to 20-23 billion dollars a year.The epidemic and experiences of the world has shown that the prevention and control of HIV/AIDS is an urgent, complex and long-term and arduous task. The Chinese Government attaches great importance to HIV/AIDS prevention and control, and the amount of funds invested in HIV/AIDS control has been growing rapidly in the past decade. On Jan 29, The State Council promulgated the " Regulations on AIDS Prevention and Treatment", which clear the AIDS funding mechanisms that Local governments at the county level or above are responsible for providing the necessary financial expenditure of AIDS prevention, control, and supervision-monitoring in accordance with their respective functions, the central financial department of the national government provides subsidies to the AIDS high epidemic area and the important projects implemented in the economically under-developed area, and national government encourages and supports the development of international co-operations and communications in AIDS prevention and treatment. The regulations clear the HIV/AIDS financing mechanisms of "government investment as the mainstay, grading commitment and multi-channel financing". The central government established a special funds for HIV/AIDS prevention and treatment, included in the annual central budget, mainly for the relevant central departments and subsidies for the areas with high disease burden and with financing difficulties.Currently, the major source of China’s HIV/AIDS funding is government financial input, and it plays a leading role with characteristics of a large volume, stable and strong sustainability. The international cooperation funds plays an important complementary role, with a relatively large number of funds.In recent years, with the rapid growth of the resources for response to HIV/AIDS epidemic, the issue of HIV/AIDS financing has been gradually paid increasing academic attention. From the research results, the following conclusions can be made: 1) Local governments have not yet fully committed to funding duties; and 2) The distribution of the central financial grants in the provinces embodies the principle of "key support for AIDS-stricken areas", but did not reflect the principle of "key subsidies for poverty-stricken areas". Due to the availability of data, researches on HIV/AIDS funding are still limited, with conclusions drawn at the national or provincial level. However, the work of HIV/AIDS prevention and control is mainly implemented at the county level. At present there is not enough studies on the issue of HIV/AIDS funding at the province, especially at the county level, and such studies has significance for the decision making and evaluation of HIV/AIDS funding. In addition, the issue of the input/output, the actual utilization and efficiency of HIV/AIDS funds is a major concern of decision-makers, but it is still blank in literatures。The main aim of this study is to reveal the fulfillment of the duties of the county-level governments in HIV/AIDS funding, and the reasonableness of the allocation of central financial resources among the counties, and the factors impacting the efficiency of fund utilization, through the analysis of financing, distribution and utilization of HIV/AIDS funds.METHODSQuantitative analysis along with case analysis is used in this study. According to the objectives, HIV/AIDS epidemic and funding data from 2004 to 2006 of 181 counties in Sichuan Province were collected, and epidemic and input/output data from 2005 to 2007 of 72 project counties in seven provinces (Anhui, Hebei, Henan, Hubei, Shandong, Shanxi and Shannxi Province) in middle China were collected for analysis.Statistical analysis methods used include descriptive analysis, ANOVA, Probit model and linier regression。The data structure collected for this study are all panel data (cross-sectional time series data). The statistical analysis of panel data needs special handling, which includes adjustment of degree of freedom for repeated measure in ANOVA, dividing the regression model into between and within model, which is further divided into fixed effect model and random effect model.The software of MS Excel is used for descriptive analysis, and StatalOis used for statistical model analysis.RESULTSThe percentage of counties which established special funds for HIV/AIDS prevention and control is very low. In 2004, only 16 counties (8.84%) among 181 counties setup a special HIV/AIDS fund, with otal amount of 0.48 million yuan,the maximum amount of 100 thousand yuan and minimum amount of 2 thousand yuan; and in 2005, only 28 counties (15.47%) among 181 counties setup a special HIV/AIDS fund, with total amount of 1.57 million yuan, the maximum amount of 200 thousand yuan and minimum amount of 3 thousand yuan。The number of HIV/AIDS cases reported and GDP per capita have no statistical significant impacts on the amount of HIV/AIDS funds at county level。Although the number of population has significant impact on the amount of HIV/AIDS funds, its actual effect is relatively small, with R square only 0.045 in the regression model.The number of HIV/AIDS cases reported, number of population and GDP per capita all have statistical impacts on the amount of HIV/AIDS funds, but the main effects come from the variable "the number of HIV/AIDS cases reported", and the effects of the other two variables are relatively small。The distribution of the central financial grants at the county level embodies the principle of "key support for AIDS-stricken areas", but did not reflect the principle of "key subsidies for poverty-stricken areas".From 2005 to 2007, the fulfillment rate of HIV/AIDS fund was gradually increasing. In 2007, the average rate was up to 98.36%. The proportion of funds for multi-sectional cooperation in HIV/AIDS control was increasing, and it was about half of the total activity fund. The organizations involved in the cooperation included trade unions, the Communist Youth League, women’s federations, the Red Cross, Family Planning Commission, the relevant institutes and associations, academic institutions and Grass-roots organizations. The average amount of fund for each multi-sectional activity was 15 thousand yuan, ranging from one thousand to hundreds of thousands of yuan.The unit cost of VCT varied between provinces and periods, ranging from 30.25 yuanto 356.65 yuan. The unit cost of VCT was decreasing, from 100.24 yuna in the beginning period to 61.63 yuan in the latest period, down 38.52%. The regression model suggests that the unit cost of VCT will decrease 30% if the total fund invested in VCT increased by 100 thousand yuan.The unit cost of ART varied greatly provinces and periods, ranging from 51.84 yuanto 8601.06 yuan. Contrary to the trend of unit cost of VCT, the unit cost of ART was increasing, from 193.55 yuna in the beginning period to 450.92 yuan in the latest period, up 3.82 times. The regression model suggests that the unit cost of ART will increase 81% if the total fund invested in ART increased by 100 thousand yuan.The AIDS program in 72 counties in middle China has achieved remarkable results. Compared with 2005,the percentage of general population who both correctly identify ways of preventing the sexual tranmission of HIV and reject major misconceptions about HIV increased 32 percentage points in 2007, and this percentage of FSW increased 32 percentage point. The percentage of sex workers who report using a condom with their most recent client increased 13 percentage point in the same period. CONCLUSIONS AND RECOMMENDATIONSLocal governments did not perform their duties of financing for HIV/AIDS. In general, county level governments has a serious shortage of financial input in HIV/AIDS. It is recommended that the central government should adopt effective measures to enable local governments to assume the due responsibilities of financing HIV/AIDS. The financial inputs in HIV/AIDS of local governments especially county governments should be specifically identified and quantified. Local financial input should accord with their financial capacity. Economically developed counties should invest more funding, while economically underdeveloped areas can input less funding. The funding gap of underdeveloped areas can be complemented by the financial transfer payment of central and provincial governments.The allocation of the central financial grants at the county level embodies the principle of "key support for AIDS-stricken areas", but did not reflect the principle of "key subsidies for poverty-stricken areas". It is recommended that the allocation schemes of central and provincial HIV/AIDS funding should be opened and clearly justified. The function of transfer payment of central financial funding should be embodied in the allocation schemes. The central and provincial government should strengthen subsidies to the economically under-developed areas.In the process of HIV/AIDS project implementation, researches should be made on efficiency and factors impacting efficiency, and according to the results of the researches, allocation of fund should be adjusted so as to enhance the efficiency of the fund utilization. Take VCT and ART as an example, the results of this study show that efficiency of VCT improves with the increase of input in VCT, so from the aspect of efficiency, the sustainability of funding for VCT should be guaranteed after the close of AIDS project. On the contrary, the efficiency of ART decreases with the increase of input in ART. The decision-makers could set a efficiency threshold according to the results of measurement, and the funds deficiently used below the threshold may be transferred to other work fields or other areas, so that to improve the efficiency. However, under normal circumstances, the procedures for such fund transfers are complex and difficult。This problem should be first resolved.更多还原