中国卫生系统公平性探析

发布时间：2018-08-10 20:51

【摘要】：研究背景在过去的几十年中,世界各国为建立运行良好的卫生体系,促进卫生体系的公平性做出了无限的努力,也取得了巨大的成绩。但令人痛心的是,遵循被验证为正确的《世界卫生组织宪章》和《阿拉木图宣言》倡导的价值观所指引的初级保健运动却没有成功。由此导致卫生体系更大的不公平,中国亦是如此。《2000年世界卫生报告》对中国卫生系统的排名如下：在191个成员国中,中国卫生系统总体绩效排在第144位,整体达标成就(卫生进展总体水平)排在第132位,卫生负担公平性排在第188位。我国如何从落后的排名中,汲取教训,从而迎头赶上是卫生界特别关注的问题。中国2009年启动的新医改让人们看到了希望,然而改革远未成功。虽然描绘的蓝图很美,但也如同其他改革一样,步入了深水区。中国卫生改革之路任重而道远,提高卫生系统公平性,成为中国未来很长一段时间需要实现的目标。研究目标消除不公平现象是人类的理想,对于卫生系统的不公平我们亦是如此态度。因此,本研究站在公平的角度上,通过量化比较,对中国卫生系统从国际、省际、城乡层面,分3个时间段(1997年以来、近8年以来,2009年以来),探讨其公平性状况,分析其原因,提出政策建议。旨在探明十多年来中国卫生系统公平性的发展规律,通过对规律的把握,丰富中国卫生体系公平性理论与经验,从而促进全体居民健康水平的提升。资料来源与研究方法资料来源：国际部分主要数据来源：((World Health Statistic2008-2015》。国内部分的主要数据来源：《2008-2013中国卫生统计年鉴》、《2014-2015中国卫生和计划生育统计年鉴》。数据分析：采用Excel 2007录入、SPSS 15.0整理分析。(一)比较研究法本研究主要采用比较分析研究法。通过数据处理,量化中国卫生系统的公平性状况,综合使用了横向比较与纵向比较方法。横向比较分为国际与国内比较,国内比较分为省际与城乡比较,亦即对中国卫生系统公平性从国际、省际、城乡3个层面进行探讨。横向比较得出相对公平的状况,纵向比较得出绝对公平的状况。相对公平与绝对公平构成研究中国卫生系统公平性的两个基本维度。纵向比较根据资料的可得性分成不同时间段进行比较,时间段的划分重点考虑1997年及2009年两个重要时间节点。原则是尽可能纵深至1997年,尽可能使用最新的数据。比如中国卫生筹资国际公平性的比较,分为3个阶段：1997年-2012年卫生系统公平性的纵向比较；2005年至2012年卫生系统公平性的纵向比较；2009年-2012年新医改后卫生体系公平性的纵向比较,即对中国卫生系统公平性从16年、8年、4年3个时间段进行纵深比较。其中16年的比较偏重2012年与1997年两个时间点的公平性状况静态比较,而8年与4年时间段的比较侧重于变化趋势即动态的比较。囿于资料可得性、世界卫生统计数据截止时间与中国卫生统计截止时间不同等原因,时间段的划分只是大致的。各章、国际比较与国内比较的起止时间有时不完全一致,比如中国卫生筹资国内公平性的比较,国内比较的3个时间阶段为：1997年-2013年,2005年至2013年,2009年-2013年。个别数据截止时间为2014年的,则将比较时间延至2014年。(二)典型研究法本研究国际比较部分采用典型研究法,即选择几个典型国家进行对比研究。目前中国已经是世界第二大经济体,正处于大国崛起的时期,有必要多研究其它经济大国的情况。根据这个研究的目的,为了解中国卫生系统公平性在世界中的状况,我们选取了6个国家与中国进行比较,以形成有意义的研究成果。(三)实证分析和规范分析相兼顾的方法对中国卫生系统的公平性状况数据的采用,数据处理,量化结果的获得方面使用了实证研究方法,力求客观反映事物的本来面目,尽可能减少研究者的主观判断。但是对于社会科学来说,摒除个人价值观的的所谓“纯客观研究”是难以企及的。本研究也大量使用了规范研究方法,并且在实证研究中也渗透了一定的价值判断。因此,在使用实证分析法的同时,结合了规范分析法。(四)文献法对卫生系统公平性方面的文献进行了收集与判研,由此确立本研究的思路、方法与指标。研究框架将中国卫生系统这个研究对象,分为国际、省际与城乡3个层面,将卫生系统公平性这个研究主题分为健康公平性、卫生筹资公平性与卫生服务可及性的公平性3种类型。对研究对象开展横向与纵向比较,横向比较得出相对公平的状况,纵向比较得出绝对公平的状况。相对公平与绝对公平构成研究中国卫生系统公平性研究的两个基本维度。研究分为3个步骤：探明公平性状况—分析公平性状况原因—提出解决公平性问题的对策。主要结论1.公平是介于公正与平等之间的一种正义形态。公平性是指某事物的公平属性,表示一个事物具有公平性质的程度。2.正义是社会制度的首要价值,卫生系统同样要坚持这一理念。公民拥有健康权,国家有保障公民健康权的义务。3.中国健康公平性包括预期寿命、孕产妇死亡率、婴儿死亡率、五岁以下儿童死亡率、新生儿低重率等方面的公平性。自1990年以来,国际、省际和城乡间公平性不断增强。健康状况高于全球平均水平,在七个比较国家中排名第五位,胜过印度和巴西(或者俄罗斯)。但是国内城乡婴儿死亡率、城乡五岁以下儿童死亡率有一倍以上差距,相对公平略差。影响中国健康公平性的主要因素有：(1)社会经济文化因素：与收入增长、是否拥有基本卫生资源有关。(2)教育因素。(3)母乳喂养和辅食添加质量。(4)出生率的高低。(5)喂养因素。4.卫生筹资公平性主要体现在私人卫生支出占卫生总费用比重方面。中国在1997-2014年间,私人卫生支出占卫生总费用比重明显下降。这说明我国个人负担大幅度减轻,卫生筹资公平性明显增强,并且扭转了1997年的严重不公平局面。按国内统计口径,个人卫生支出已接近30%的目标。但是,按国际口径,离此目标尚有较大差距。各省份卫生筹资公平性虽得到了改善,然而农村居民获得的卫生资源仍然远不如城市居民。中国卫生总投入不足,无论是过去还是现在都落后于全球平均水平。影响中国卫生筹资公平性的主要因素有：(1)提高社会保障资金筹资能力。(2)政府预算增加。(3)经济实力增强。(4)居民收入差距。(5)中央财政转移支付对中部的支持力度不够等等。5.中国卫生系统免疫覆盖率与生殖健康服务的公平性,无论是国际还是城乡均比较强。中国的医生数量的公平性在国际上表现为一般,31个省份的卫生技术人员的公平性较好。中国的床位数方面公平性强,处于世界领先地位,省际间也相对公平。但是城乡居民在卫生服务利用上尚未得到充分提升,公平性有所欠缺。影响中国卫生服务可及性公平性的主要因素有：(1)经济发展水平阶段的不同。(2)中国政府高度重视妇幼工作。(3)各省份经济实力不同。(4)母亲文化程度。(5)地理可及性等方面。政策建议在论述了中国卫生系统公平性的相关规范,探析了其公平性状况与成因后,为增进其公平性,提出了针对性对策建议。政策建议构建的流程为：提出政策建议构建框架,确定提出政策建议的主要依据,提出具体政策建议,分析政策执行力。根据罗伯逊(Marc J. Roberts)等人提出了的卫生系统绩效控制柄理论建立了政策建议构建框架,确立理论依据、权威文献和本文前段的研究成果为政策建议的主要依据。根据以上流程,得出5条具体政策建议：1.确立卫生大国理念,做健康责任担当者表率。2.制定《基本医疗卫生法》,确保卫生公平有法可依。3.巩固医疗保障领域卫生改革的成果,促进公平的医改方案全面实施。4.改善弱势群体状况,促进最不优惠者卫生公平5.广泛纳入公民参与卫生政策制定,为卫生公平提供政治保障。最后从国家的管理能力、公民对政府态度两方面,对五条具体政策建议,进行了执行力分析,确信了它的执行力。特色与创新1.通过横向与纵向比较,对中国卫生系统公平性进行了比较全面与深入的剖析。从相对公平与绝对公平两个基本维度,对中国卫生系统的3个层面、3种公平性类型,在3个历史阶段的公平性,分3个研究步骤进行了逐一探讨。从而揭示了中国卫生系统公平性的健康、卫生筹资、可及性的公平性3种类型,在国际、省际与城乡层面上,自1997年以来的3个历史阶段的发展规律,从整体上认识我国卫生系统公平性16年来的基本脉络。2.对学科概念进行了新归纳由于卫生服务是卫生系统最重要的职能,国内大多数学者将对卫生系统公平性的研究,冠名为卫生服务的公平性研究。其实称之为卫生系统的公平性更为确切些。本研究在已有研究成果的基础上,对本领域的“卫生服务公平性”概念的外延与名称作出了新思考,比如使用“卫生系统公平性”指称“卫生服务公平性”。对学科概念的新思考,可以促进学科体系的发展。3.政策建议的研制过程有所创新政策建议分4步完成：确定政策建议构建框架、确定提出政策建议的主要依据、提出具体建议、分析政策执行力。具体建议根据以上流程制定,防止出现政策建议与前面的研究成果“两张皮”现象,防止政策建议流于空泛。
[Abstract]:Background Over the past few decades, countries around the world have made tremendous efforts to establish well-functioning health systems and promote equity in health systems. The World Health Report 2000 ranked China's health system as 144 out of 191 member countries, 132 out of 191 with overall health achievement (overall level of health progress) and negative health. China's health sector is particularly concerned about how to learn from its backward rankings and catch up with them. The new health care reform launched in 2009 has given people hope, but the reform is far from successful. The road to reform is long and arduous. Improving the equity of the health system will be a long-term goal for China in the future. From the international, inter-provincial, urban and rural levels, divided into three periods (since 1997, nearly eight years, since 2009), to explore the status of equity, analyze its causes, and put forward policy recommendations. Data Sources and Research Methods Data Sources: International Major Data Sources: (World Health Statistical 2008-2015 >. Domestic Major Data Sources: China Health Statistics Yearbook 2008-2013 >, < China Health and Family Planning Statistics Yearbook 2014-2015 >. Cel 2007 entry, SPSS 15.0 collation and analysis. (1) The comparative research method is mainly used in this study. Data processing is used to quantify the fairness of China's health system. Horizontal comparison and vertical comparison are used. Horizontal comparison is divided into international and domestic comparison, while domestic comparison is divided into provincial, international and urban-rural comparison, that is, provincial, international and Urban-Rural comparison. The equity of China's health system is discussed from three levels: international, provincial, urban and rural. The situation of relative equity is obtained by horizontal comparison, and the situation of absolute equity is obtained by vertical comparison. The principle is to use the latest data as far as possible, from 1997 to 1997. For example, the comparison of equity in health financing in China can be divided into three stages: the vertical comparison of equity in health system from 1997 to 2012; and the health from 2005 to 2012. Longitudinal comparison of the equity of the health system after the new medical reform in 2009-2012, that is, the equity of the health system in China was compared in depth from 16 years, 8 years and 4 years. Due to the availability of data, the cut-off time of World Health Statistics is different from that of China's health statistics, and so on, the division of the time period is only rough. Comparisons are made in three stages: 1997-2013, 2005-2013, 2009-2013. The deadline for individual data is 2014, and the comparison time is extended to 2014. (2) Typical research method is adopted in the international comparison part of this study, i.e. several typical countries are selected for comparative study. As the second largest economy in the world, it is necessary to study the situation of other economic powers. According to the purpose of this study, in order to understand the fairness of China's health system in the world, we selected six countries to compare with China in order to form meaningful research results. (3) Empirical analysis and norms. Empirical research methods are used in the adoption of fairness data, data processing, and quantification results of China's health system to objectively reflect the true nature of things and minimize the subjective judgments of researchers. Objective research is difficult to reach. This study also uses a large number of normative research methods and permeates certain value judgments in empirical research. Therefore, while using empirical analysis method, it combines normative analysis method. (4) Literature method collects and judges the literature on health system equity, and establishes this book. The research framework divides China's health system into international, provincial and urban-rural levels, and divides the research topic into three types: health equity, health financing equity and health service accessibility equity. Relative fairness and absolute fairness constitute two basic dimensions in the study of equity in China's health system. The study is divided into three steps: identifying fairness conditions - analyzing the causes of fairness conditions - and proposing countermeasures to solve equity problems. Justice is a form of justice between justice and equality. Justice refers to the fairness of something and the degree to which a thing has a fairness nature. 2. Justice is the primary value of the social system. The health system should also adhere to this concept. Citizens have the right to health, and the state has the obligation to protect citizens'right to health. 3. China Health equity includes life expectancy, maternal mortality, infant mortality, under-five mortality, and low birth weight. Since 1990, international, inter-provincial and inter-urban equity has been growing. Health status is higher than the global average, ranking fifth in seven comparative countries, better than India and Brazil. However, the infant mortality rate between urban and rural areas in China is more than twice that of children under five years old, and the relative fairness is slightly worse. (4) Birth rate. (5) Feeding factors. (4) Equity of health financing is mainly reflected in the proportion of private health expenditure to total health expenditure. In China, the proportion of private health expenditure to total health expenditure declined significantly from 1997 to 2014. This shows that the burden on individuals has been greatly reduced, and equity of health financing has been significantly enhanced. According to domestic statistics, personal health expenditure has approached the target of 30%. However, according to international standards, there is still a big gap from this target. The main factors affecting the equity of health financing in China are: (1) improving the financing capacity of social security funds; (2) increasing the government budget; (3) strengthening the economic strength; (4) increasing the income gap of residents; (5) insufficient support from central fiscal transfer payments to the central government, and so on. Immunization coverage and fairness of reproductive health services in the health system are relatively strong both internationally and in urban and rural areas. The fairness of the number of doctors in China is generally shown in the international arena, and the fairness of health technicians in 31 provinces is better. However, the utilization of health services by urban and rural residents has not been fully improved, and the equity is lacking. The main factors affecting the equity of health services accessibility in China are: (1) the different stages of economic development. (2) the Chinese government attaches great importance to maternal and child work. (3) the economic strength of the provinces is different. (4) the educational level of mothers. (5) geographical accessibility. After discussing the relevant norms of equity in China's health system, analyzing the status and causes of equity, the paper puts forward corresponding countermeasures and suggestions for improving equity. Based on the theory of health system performance control handles put forward by Marc J. Roberts and others, the framework of policy recommendations is established, and the theoretical basis is established. The authoritative literature and the research results in the previous paragraph of this paper are the main basis for policy recommendations. 3. Consolidate the achievements of health reform in the field of medical security and promote the implementation of a fair health reform program. 4. Improve the situation of vulnerable groups and promote the health equity of the least favourable. 5. Widely include citizens in the formulation of health policies. Finally, from the aspects of the state's management ability and citizens'attitude toward the government, this paper analyzes the executive power of five specific policy recommendations and confirms their executive power. The two basic dimensions of equity and absolute equity are discussed in three levels and three types of equity in China's health system. The three types of equity in China's health system are discussed in three historical stages and are divided into three research steps. Since 1997, the law of development in the three historical stages has been recognized as a whole, and the basic context of equity in China's health system over the past 16 years has been recognized. 2. The concept of discipline has been newly summarized. Since health service is the most important function of the health system, most domestic scholars will study equity in the health system and call it equity in health service. In fact, it is more precise to call it equity of health system. On the basis of existing research results, this study makes a new thinking on the extension and name of the concept of equity of health service in this field, such as using equity of health system to refer to equity of health service. To promote the development of the discipline system. 3. Policy proposals are developed in four steps: to determine the framework of policy proposals, to determine the main basis for policy proposals, to make specific recommendations, and to analyze the implementation of policies. The two skin phenomenon prevents policy recommendations from being vague.
【学位授予单位】：武汉大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R197.1

【参考文献】