【作者】 俞水；

【导师】 尹爱田；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2008， 硕士

【摘要】 党的十七大报告中指出:“要坚持公共医疗卫生的公益性质”、“强化政府责任和投入”,进一步明确了公共卫生事业的发展方向和政府在卫生领域的责任。多年来,由于政府财政补偿不足,医疗卫生机构逐利倾向明显、诱导需求严重,看病贵、医患关系紧张;公共卫生机构开展收费项目创收,部分职能偏废、公共卫生指标恶化;基层卫生机构发展陷入困境。无论是政府官员、研究者,还是社会均呼吁政府在卫生领域的责任回归。山东省是全国的缩影,也面临着同样的问题。自1997年起特别是2003年“非典”过后,政府出台了一系列有关卫生改革、卫生体系建设的政策文件,开始对卫生财政政策进行调整。研究者们也开展了大量的调查研究,尤其是对公共卫生机构、农村和基层卫生机构的补偿作了大量的研究工作。但是这些研究大多是微观或中观层面的对某一类机构的补偿,较少从政策制定者角度对卫生财政的补偿总量、财政资源有限情况下卫生经费如何分配等方面给予关注。而根据现行政策要求对卫生财政补偿总量、卫生经费的分配结构等问题进行研究,对资金投入者来说更具可操作性和参考价值。本研究根据十七大提出的卫生工作方针,以保障广大人民群众的健康需求为目标,以相关政策为依据,对山东省公立卫生机构的财政补偿现况进行分析,测算山东省卫生投入总量以及分配结构,为卫生财政政策的制定和完善提供依据。具体目标有:分析目前财政政策下各类卫生服务机构的经济运行和财政补偿状况;测算依据政策要求的卫生经费投入目标数量;测算卫生改革发展趋势条件下卫生经费的合理分配结构及财政补偿建议。本研究将山东省主要的公立卫生机构分为三类,即县及县以上医院、公共卫生机构(包括疾病预防控制机构、卫生监督机构、妇幼保健机构)、基层卫生机构(包括乡镇卫生院和社区卫生机构)。依据统计资料分别对这三类机构的筹资渠道,2006年的主渠道补偿水平、财政补偿、收支结余和资产负债情况进行了分析;对县及县以上医院、公共卫生机构进行了省、市、县三级的分层比较;考察了2002-2006年各类机构的财政补偿变化情况;以1997年《中共中央、国务院关于卫生改革与发展的决定》中“中央和地方政府对卫生事业的投入,增加幅度不低于财政支出的增长幅度”的要求测算了2006年卫生经费的应投入额及实际投入与理想值的缺口。根据公共产品理论、成本效益原则及国际经验,确定卫生经费的优先投入领域为公共卫生和基层卫生机构。应用专家咨询法,对公共卫生和基层卫生机构常规经费的应补偿比例作了估计,在此基础上对现有卫生经费和理想卫生经费的分配分别进行了测算。本研究的主要结果:1)与经济发展水平相比,山东省对公立卫生机构的财政补偿总量呈相对下降趋势,人均补偿水平处于全国中下游水平。2)县及县以上医院财政补助占总收入比重不足10%;疾病控制机构省市级以财政补偿为主,县级则以事业收入补偿为主;卫生监督机构主要收入来源是财政补助;妇幼保健机构最主要收入来源为事业收入,人均财政补偿水平低于同级疾病控制和卫生监督机构,省级财政补偿明显高于市、县级;基层卫生机构仍以药品收入为主要收入来源,财政补偿水平低。省、市级公共卫生机构出现了普遍亏损。各类机构的资产负债率整体偏高,特别是基层卫生机构,多年来资产负债率一直在40%以上。3)各级公立卫生机构的财政补偿水平存在较大差异。财政对省级的补偿水平明显高于县市级;基层卫生机构的常规经费补偿远低于其人员和公用费用。4)山东省卫生经费的增长慢于财政支出的增长,按照中央对卫生事业投入的政策要求测算,2006年政府投入资金缺口达29.23亿元。根据我国卫生政策的要求,按照优先补偿公共卫生和基层卫生机构的原则,现有卫生经费至少应有73.49%、理想卫生经费至少应有42.50%投入到公共卫生和基层卫生机构。政策建议:1)规范对卫生事业单位的财政投入。形成规范、稳定、增长的卫生补偿机制,对目前缺口较大的问题,采用分阶段实现、逐步提高的方式。2)依据相关政策调整财政资金的分配结构。建立卫生财政的目标导向机制,优先实现对公共卫生类机构和基层卫生机构的财政补偿。3)界定医疗机构的财政支持范围。根据区域卫生规划和财政支付能力,合理规划公立医疗机构的数量、规模和布局。4)调整并明确各级财政的支出责任。加大省级财政的转移支付,通过专项补助等方式提高省级财政分担比例,增加对县乡两级承担公共卫生服务机构的补偿额度。5)加强对投入资金的监管与绩效评价。更多还原

【Abstract】 The 17th CPC National Congress Report pointed out: "We must maintain the public welfare nature of public medical and health care services, " and "We will increase government responsibilities and spending", which further defined the direction of the development of public medical and health care services and the government’s responsibilities in the field of health. Over the years, due to lack of governmental financial compensation, profit-driven health care institutions tended to induce demand, which led to high medical cost and tense relationship between doctors and patients. Public health institutions preferred to deliver income-generating services and pubic health services delivery were insufficient, resulting in some of the public health indicators worsened. The primary health institutions developed difficultly. Government officials, researchers, and the whole society all appealed to government increasing their responsibilities in the field of health. Shandong Province is the epitome of the country, also faces such problems.Since 1997, in particular after "SARS" in 2003, the government promulgated a series of policies about health reform and the building of health service system to adjust fiscal policy. The researchers also did a great deal of investigation and research, especially on the financial compensation of public health institutions, rural health and primary health institutions. However, most of these studies were on the compensation for a certain type of health institutions in the concept of micro-level. The research on the amount and allocation of the health financial funds from the policy-makers’ perspective was few, although it might be more operational and valuable for the fund dominator.According to the 17th CPC National Congress guideline and relevant policies, to satisfy people’s health needs, this study aims to analyze the status of financial compensation for public health institutions in Shandong Province and calculate the amount and the allocation of the health funds, to give suggestions to health fiscal policy makers. The special objectives are: to analyze the status of the economic operation and financial compensation of different types of public health institutions under current fiscal policy; to calculate the amount of health funds based on the requirement of the policy; to calculate the rational allocation of health funds following the trend of health reform and development, and give suggestions on health financial compensation.In this study, the main public health institutions were divided into three types, namely, the county and above level hospitals, the public health institutions(including disease prevention and control institutions, health inspection and supervision institutions, maternal and child health care institutions), the primary health care institutions (including township hospitals and community health institutions). Based on the statistics data, the fund-raising channels, the level of compensation from main channels in 2006, the financial compensation, balance, and assets and liabilities of the three types were analyzed. The comparison among different levels was made, including the province level, city level, and county level of the county and above level hospitals and public health institutions. The change of the financial compensation in 2002-2006 was also described. The ideal amount and the gap of governmental health fund were estimated, according to "the decision of CPC Central Committee and the State Council on Health Reform and Development"(1997), which required the increasing speed of governmental health input should not be slower than that of fiscal expenditure. Base on the public goods theory, the principle of cost-effectiveness, and international experience, public health and primary health institutions should be given priorities in health financial input. In this study, the rational compensation level of running expense in public health and primary health institutions were estimated by experts, and on this basis, the allocation of actual and ideal health subsidies was analyzed separately.The major findings of this study: 1) compared with the development of economy, the level of financial compensation for public health institutions in Shandong Province is relatively declining. 2) The governmental subsidies is less than 10% of the total income for the county and above hospitals; the CDCs’ money comes mainly from the government subsidies at p province and city level, but from undertaking revenue at the county level; the health inspection and supervision institutions’ main income source is financial compensation; the maternal and child institutions raise money mainly from undertaking revenue, with less financial support than the CDCs and health inspection and supervision institutions, and the province level has a higher financial compensation level than the city and county level; the primary health institutions still rely on selling drugs to be their most important income source with a low financial compensation level. The phenomenon of running under deficit exists widely among public health institutions at province and city level. The asset-liability ratios of the institutions are high overall, among which the primary health institutions have an especially high ratio, staying higher than 40% over the years. 3) The financial compensation levels differ greatly among different levels. The provincial institutions’ financial compensation level is significantly higher than that of the county and city level. The primary health institutions’ regular governmental subsidies are far below their running expense. 4) The health fund increased slower than the fiscal expenditure. In accordance with the policy requirement of the central government, there is a fund gap of 2.923 billion yuan in 2006. According to the policy requirement and the principles of giving priorities to public health and primary health institutions, at least 73.49% of the current and 42.50% of the ideal health subsidies are needed to give to these two types of institutions. Policy recommendations: 1) increasing the financial investment for public health services. A stably growing compensation mechanism is needed. The large fund gap may be fulfilled by several stages. 2) Adjusting the allocation strategy of health subsidies based on relevant policies. Goal-oriented health compensation mechanism should be established, and priorities should be given to public health and primary health institutions. 3) Defining the funding scope of support for medical institutions. The number, size, and distribution should be planned more rationally according to regional health planning and financial capacity. 4) adjusting and making clear funding responsibilities of the government at different levels, increasing the provincial financial transfer payments and enhancing the sharing ratio of provincial level by the way of special subsidies. The institutions delivering public health services at county and township level should be given more financial support. 5) Strengthening the supervision of investment and developing performance evaluation.更多还原