【作者】 应晓华；

【导师】 胡善联；

【作者基本信息】 复旦大学 ， 社会医学与卫生事业管理， 2003， 博士

【摘要】 一、研究背景和研究目的改革开放以来，我国的经济取得了长足的进展，但同时，由于多种所有制经济并存，我国居民的收入水平差距也越来越大。根据世行专家估计，我国在1995年的收入Gini系数为0.39，如果考虑到对城镇居民的实物补贴，则可能已经超过了0.45。而且，近年来的贫富差距还在不断扩大。与此同时，农村合作医疗制度由于失去了集体经济的大力支撑，覆盖率急剧下降，绝大多数农民成为医疗服务的自费者。贫富差距的增大和医疗保障体制的弱化，导致的一个直接后果就是居民的卫生服务筹资越来越不公平。卫生服务的公平主要包括三种：卫生服务利用的公平性、卫生资源分布的公平性和卫生服务筹资的公平性。卫生服务筹资公平性主要有两层含义：筹资的水平公平和筹资的垂直公平：水平公平主要指同等收入的人群，应该支付同等份额的卫生筹资；垂直公平主要是指高收入人群应该比低收入人群支付更多金额和更高比例的卫生服务筹资。世界各国在卫生服务筹资中，遇到的最大问题是无法保证脆弱人群在卫生服务筹资过程中的公平，我国也遇到了相似的问题。越来越多的证据表明在我国，穷人自付医药费用无论是金额还是比例都要高于富人，这加剧了穷人的负担，拉大了贫富差距。如何建立一个具有良好风险共担(risk pooling)和风险分担(risk sharing)的筹资体系，尽量降低疾病给家庭带来的负担和保证穷人的利益，是所有国家面临的一个共同难题。WHO在《2000年世界卫生报告中》把卫生服务筹资公平性作为卫生系统绩效的三大目标之一，并提出了新的卫生系统筹资公平性测算方法。WHO认为，如果所有人群家庭卫生支出占其可支配收入的比例完全相同，则表明卫生服务筹资就是公平的，反之，则认为卫生服务筹资不公平。这种方法在世界各地引起了许多争议，争议主要集中在这种方法的适用性和合理性上。但是这种方法的意义不在于其本身是否完全合理，而在于它是一种全新的、把世界各国的卫生服务筹资公平性进行比较的测算方法。虽然国内很多专家都认为，我国现在的卫生服务筹资很不公平，但到目前为止，尚未见关于我国卫生服务筹资公平性的相关研究和文献。为了明确我国卫生服务的筹资不公平现象并揭示其内在的影响因素，本研究将对我国目前的卫生服<WP=8>务筹资不公平程度作一个测算，并重点估算经济因素和财政卫生补助的影响程度。除此以外，本研究还将计算我国筹资系统本身所存在的缺陷给卫生服务筹资带来的垂直不公平和水平不公平程度。由于卫生服务的不公平表现为地区不公平和个体不公平，因此，本研究将对这两部分分别作测算。在本研究中，地区不公平主要指三大类地区之间和各省市之间的卫生服务筹资不公平，而个体不公平主要是指家庭卫生服务筹资的不公平。除此以外，本研究还将对WHO所提供的家庭卫生服务筹资公平性方法作一个评价，以表明这种方法在我国的适用性，并评估这种方法所测算出我国的卫生服务筹资不公平是否可信。二、研究方法在研究各省市之间的筹资不公平性时，本研究主要借鉴了经济学上测算筹资不公平的方法：Theil index和Gini系数来测算不同地区、不同省市之间卫生服务筹资的不公平；在测算经济水平和财政卫生补助对卫生服务筹资不公平性的影响时，使用了差异中差异(Difference in difference)的方法；在测算家庭卫生服务筹资不公平性时，主要使用了WHO推荐的HFC(health finance contribution，家庭卫生筹资贡献率)和FFC。除此以外，针对HFC存在的缺陷，用了RE(redistributive effect，再分配效果)、Kakwani指数的方法来测算卫生服务筹资体系中的累进性、垂直不公平和水平不公平情况。各类方法和指标的含义及其计算详见论文相关部分。三、三类地区的划分和资料来源本研究中，选取了三类地区，对三类地区间和地区内各省市之间的卫生服务筹资公平性进行了测算。这三类地区主要是依据经济水平的差异来划分的，经过2000年各省市人均GDP的比较，发觉我国传统意义上的东部、中部和西部地区很好地代表了我国的三个不同经济发展水平，因此，决定用传统意义上的三大区域来作为本研究的三类地区。其中，东部地区的12个省市为：北京、天津、河北、辽宁、上海、江苏、浙江、福建、山东、广东、广西、海南；中部地区包括的9个省为：山西、内蒙古、吉林、黑龙江、安徽、江西、河南、湖北、湖南；而西部地区则包括重庆、四川、贵州、云南、西藏、陕西、甘肃、青海、宁夏、新疆10个省市。<WP=9>本研究的数据包括两部分，第一部分是卫生部的《1992年卫生事业费决算资料》和《2001年全国卫生财务年报资料》，运用二次资料提取法，选取了其中各省市的财政卫生补助数据和卫生支出数据。第二部分是上海市四郊县的入户调查资料，采用概率抽样的选择在四个区县选取家庭进行调查。共计调查了10358户家庭，32226名居民。在计算各省市卫生服务筹资不公平性时，由于各卫生机构的筹资占总筹资的比例与各卫生机构的支出占总支出的比例之间差别没有统计学差异，两者分布的不公平性完全相等，因此，用卫生机构的支出数据来替代卫生机构的筹资数据，来表示各更多还原

【Abstract】 BackgroundWith the large economic development in China after reform and opening, the gap of individual income is growing. According to the estimation from experts of World Bank, The Gini index of China in 1995 was 0.39. In fact, the Gini index should be more larger than 0.45 if the disparity of allowance between urban and rural was considered. Furthermore, the gap of individual income was becoming larger and larger in recently years. Account for the lack of sustaining from collective economic units, the coverage ratio of RCMS(rural cooperative medicine scheme) decreased sharply in these years and most of farmers were out-of-pocket in the use of health care. The larger gap of individual income and the weakness of health insurance brought the inequity of health care finance more and more. Three types of equity were viewed in health care, which include equity of health care utilization, equity of health resource distribution and inequity of health care finance. Two axioms were concerned in inequity of health care finance: horizontal equity of health care finance and vertical equity of health care finance. Horizontal equity means health expenditure of household is same when the household has the same income, vertical equity means health expenditure of household should increase in both account and ratio to income with respect to household’s income. It is very difficulty to decrease the vulnerable groups’ economic burden of disease, which is the main obstacle in equity of health care finance in developed countries and developing countries. More and more proof were find that the poorer pay more for health care than the richer in China, and what enhance the burden of poorer. Government all over the countries expect to establish a perfect health care finance system with good risk pooling and risk sharing and decrease the poor people’s economic burden of disease. <WP=13>In <<world health report 2000>>, health care finance was one of performances of health system, and a new method of health care finance was introduced. With the opinion of experts of WHO, health finance is considered perfectly fair if the ratio of total health contribution of household to their effective non-subsistence income is identical for all households. Many criticism to this method were arise, and most of them were focus on its suitable and reasonable. But the significance of this method is this is the new way of health finance calculation, and this way will be spreaded and will be adopted to calculate the equity of health finance in all over the world by WHO. A lot of experts in China consider that it’s inequity in health care finance in China, but so far no research on it were reported and no reference about inequity in health care finance were published. This study calculated the inequity of Chinese health finance and explored its influence factors. The inequity of health finance accounting for the income gap between provinces and government expenditure on health care were estimated. Furthermore, horizontal inequity and vertical inequity were calculated. In this study, inequity in regions and individuals were calculated because inequity of health finance presented not only in different regions but also in individuals. Provinces were grouped in three type of regions, inequity in which is the provinces’ inequity. Individual’s inequity means inequity in household. To approve the suitable in China, evaluation to method of health care finance provided by WHO were made. MethodologyIn order to calculate the inequity of health care finance in different regions and different provinces, Theil index and Gini index were introduced. To calculate the degree of inequity health care finance influenced by economic status and government expenditure on health care in different regions and different provinces, difference in difference was used. In addition, we adopted HFC(health financial contribution) and FFC(fairness of financial contribution) to calculated inequity of household health financial contribution. With res更多还原