健康公平导向的基层卫生服务设施空间规划策略研究
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摘要
本文尝试探索以健康公平为导向的基层卫生服务设施的空间规划策略。公平性是一个多元概念,在哲学、政治学、法学、经济学和社会学等不同的学科语境下,它具备不同的内涵。对个体而言,健康公平关乎一个人获得其他生活资源的能力;对社会而言,健康公平不仅决定着一个社会是否正义,也决定了一个社会需要多少福利进行再分配。目前,各国医疗卫生资源分配的原则,被归纳为主要基于平等主义、优先主义和充足主义三种理论,深刻地影响着各国在卫生资源福利分配政策、卫生资源重点投向、医疗保险等方面的宏观体制设计。在编制规划时,需要充分理解我国社会资源分配的基本原则和医疗卫生资源分配的顶层设计。同时,健康服务横跨了地理和空间环境、卫生科学和经济学等不同学科领域,各级设施的空间规划需由卫生规划和城市规划部门共同完成,而各学科对公平性的概念的定义和评价方法不尽相同。因此,在制定卫生服务设施的空间规划策略时,需要厘清卫生规划和城市规划对于公平性评价的异同,选择适合的评价体系和工具。本文因而主要分两个部分:首先,通过分别对地理和空间环境与卫生科学两个领域的相关文献进行综述,厘清公平性的概念和评价方法;然后,针对医疗卫生设施的规划,归纳两个学科领域实现公平时各自的侧重点和方法,找出不同因素之间的关联,并在此基础上提出实现健康公平的设施规划策略。策略的第一步是根据我国基本公共卫生服务均等化的原则,在每个城乡社区都规划设置基层卫生服务站点,以提高卫生设施的整体可达性。然而,正如卫生资源的社会供给并不等同于个体的健康获得,基层卫生服务设施的可达也不同于健康服务的可及。实现对医疗卫生设施和资源公平分配,并不等于就实现了健康公平。因此,策略的第二步是在地方行政层级的卫生服务设计上,基于平等主义原则,对研究区医疗卫生服务供需的现状进行调查和描述,通过公平的资金筹措,对现有的医疗资源进行更加公平的分配。在设施可达性差的区域,适当增加基层设施的服务内容并提高服务质量,以提升这些设施的服务能力和利用效率,并最终提高研究区健康服务的整体可及性,提升城乡设施居民的服务利用率,满足他们的健康服务需要,向实现全民健康公平的目标迈进。
This paper explores the health equity-oriented spatial planning strategies for primary health service facilities. Health equity, however, has many aspects, and is best seen as a multidimensional concept. It has different connotations in different disciplines such as philosophy, political science, law, economics, and sociology. To individuals, it affect ones' capability to obtain resources for living. To a society, it is not only the indicator for social justice, but also the major factor decides the total amount of social welfare needed for redistribution.At present, the major principles used in medical resources allocation in all countries are the application of three theories:Egalitarianism, Prioritarianism and Sufficientarianism, which profoundly affects each country's macro structure of social warfare in terms of healthcare and health insurance policies.As a medical planning aims to materialize the prime principles of social resource allocation and the overarching design of health resource allocation, understanding those principles in China is crucial.Furthermore, health service cross over different disciplines such as geographic and spatial environment, medical science and economics. In China, the spatial planning of medical facilities at all levels needs the co-operations of health and urban planning authorities, to whom the definitions and evaluation methods of equity are different. Therefore, when developing spatial planning strategies for health services, it is necessary to clarify the similarities and differences between health planning and urban planning for equity evaluation and to select suitable evaluation systems and tools.This paper has two major parts: First, review literatures in both geographical and spatial environment and health science to clarify the EFJ concepts and evaluation methods. Second,finds out the relationship between those concepts and methods to develop the spatial planning strategies for prime medical facilities. Firstly, set up one primary healthcare service station in every urban and rural community, in accordance with the current Outline of the National Health Service System(2015-2020) to improve the overall accessibility. Nevertheless,as the capability to achieve good health does not necessarily lead to the achievement of health, the accessibility of health care facilities does not mean the accessibility of the services.The second step of the strategy is thus to investigate and visualize the current situation of the supply and demand of health services in research areas and, enrich services and/or improve quality of primary facilities in areas with healthcare shortage. As such, the overall accessibility of services increased with the utilization rate of urban and rural residents,whose needs are fulfilled towards the health equity for all.
This paper explores the health equity-oriented spatial planning strategies for primary health service facilities. Health equity, however, has many aspects, and is best seen as a multidimensional concept. It has different connotations in different disciplines such as philosophy, political science, law, economics, and sociology. To individuals, it affect ones' capability to obtain resources for living. To a society, it is not only the indicator for social justice, but also the major factor decides the total amount of social welfare needed for redistribution.At present, the major principles used in medical resources allocation in all countries are the application of three theories:Egalitarianism, Prioritarianism and Sufficientarianism, which profoundly affects each country's macro structure of social warfare in terms of healthcare and health insurance policies.As a medical planning aims to materialize the prime principles of social resource allocation and the overarching design of health resource allocation, understanding those principles in China is crucial.Furthermore, health service cross over different disciplines such as geographic and spatial environment, medical science and economics. In China, the spatial planning of medical facilities at all levels needs the co-operations of health and urban planning authorities, to whom the definitions and evaluation methods of equity are different. Therefore, when developing spatial planning strategies for health services, it is necessary to clarify the similarities and differences between health planning and urban planning for equity evaluation and to select suitable evaluation systems and tools.This paper has two major parts: First, review literatures in both geographical and spatial environment and health science to clarify the EFJ concepts and evaluation methods. Second,finds out the relationship between those concepts and methods to develop the spatial planning strategies for prime medical facilities. Firstly, set up one primary healthcare service station in every urban and rural community, in accordance with the current Outline of the National Health Service System(2015-2020) to improve the overall accessibility. Nevertheless,as the capability to achieve good health does not necessarily lead to the achievement of health, the accessibility of health care facilities does not mean the accessibility of the services.The second step of the strategy is thus to investigate and visualize the current situation of the supply and demand of health services in research areas and, enrich services and/or improve quality of primary facilities in areas with healthcare shortage. As such, the overall accessibility of services increased with the utilization rate of urban and rural residents,whose needs are fulfilled towards the health equity for all.
引文
[1]约翰·罗尔斯.正义论[M].北京:中国社会科学出版社,1988.
[2]峗怡.论卫生资源公平分配的平等主义、优先主义和充足主义[J].西南政法大学学报,2016, 8(3):43-9.
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[15]车莲鸿.卫生服务空间可达性度量方法与应用领域[J].中国卫生事业管理,2013, 02):88-91.
[16]王法辉,罗卫,程杨.就医便捷度的度量、影响与优化[M]//施迅,王法辉,地理信息技术在公共卫生与健康领域的应用.北京;高等教育出版社.2016:183-209.
[17]DOUGLAS B, MORRIS J, SMITH C, et al. London:Department of Health and Social Security, 1980.
[18]WHITEHEAD M. The Concepts and Principles of Equity and Health[J]. International Journal of Health Services, 1992, 22(3):429-45.
[19]KAWACHI I,SUBRAMANIAN S V, ALMEIDA-FILHO N. A glossary for health inequalities[J]. Journal of Epidemiology and Community Health, 2002, 56(9):647-52.
[20]健康问题社会决定因素委员会,世界卫生组织,2008.
[21]EASTERLIN R A. Does Economic Growth Improve the Human Lot? Some Empirical Evidence A2-DAVID, PAUL A[M]//REDER M W. Nations and Households in Economic Growth:Essays in Honor of Moses Abramovitz. New York; Academic Press. 1974:89-125.
[22]DEATON A, Health, Inequality, and Economic Development[J]. Journal of Economic Literature, 2003, 41(3):113-58.
[23]MCLEOD C B, LAVIS J N, MUSTARD C A, et al. Income Inequality, HouseholdIncome, and Health Status in Canada:A Prospective Cohort Study[J]. American Journal of Public Health, 2003, 93(8):1287-93
[24]HOU F, MYLES J. Neighbourhood Inequality, Relative Deprivation and Self-perceived Health Status[M]//DMSION B A L M A. Ottawa; Statistics Canada, 2004.
[25]JUDGE K, PATERSON I. Poverty, Income Inequality and Health[M]//TREASURY N Z. Treasury Working Paper Series. New Zealand. 2001:64.
[26]O'DONNELLO, DOORSLAER E V, WAGSTAFF A, et al. Washington, D.C.:The World Bank, 2008.
[27]王丽,赵郁馨,张毓辉,et al.卫生服务利用公平性分析方法研究[J].中国卫生经济,2005,24(7):8-10.
[28]SUTTON M. Vertical and horizontal aspects of socio-economic inequity in general practitioner contacts in Scotland Authors[J]. Health Economics, 2002,11(6):537-49.
[2]峗怡.论卫生资源公平分配的平等主义、优先主义和充足主义[J].西南政法大学学报,2016, 8(3):43-9.
[3]CAPPELEN A W, EICHELE T, HUGDAHL K, et al. Equity theory and fair inequality:A neuroeconomic study; proceedings of the the National Academy of Sciences of the United States of America, F, 2014[C]. PNAS.
[4]SUN Q, CHANGQUAN LONG, CHEN A. Equality or Equity? Distributive Justice Perceptions in Different Work Contexts[J]. Advances in Psychology, 2016, 6(8):923-31.
[5]SEN A K. Poverty and famines:an essay on entitlement and deprivation[M].1981.
[6]SEN A K. On Economic Inequality[M]. Oxford:Clarendon Press, 1973.
[7]李平华,陆玉麒.可达性研究的回顾与展望[J].地理科学进展,2005, 3(24):69-78.
[8]PENCHANSKY R, THOMAS J W. The Concept of Access:Definition and Relationship to Consumer Satisfaction[J]. Medical Care, 1981,19(2):127-40.
[9]傅晓,欧阳华生.我国省际间医疗卫生资源配置公平性分析[J].卫生经济研究,2008, 2008(11):18-21.
[10]何达.我国CT和MRI配置与利用研究[D];复旦大学,2013.
[11]张雪莉.我国社区卫生服务机构主要卫生资源配置状况分析[J].中国卫生资源,2012, 15(3):271-3.
[12]袁素维,危凤卿,刘雯薇,et al.利用集聚度评价卫生资源配置公平性的方法学探讨[J].中国医院管理,2015, 02):3-5.
[13]刘雯薇,危凤卿,袁素维,et al.基于聚集度的我国城乡卫生人力资源规划评价[J].中国医院管理,2015, 03):1-4.
[14]胡慧美,陈定湾,高启胜,et al.基于集聚度的浙江省区域卫生资源配置评价分析[J].中国卫生经济,2016, 35(7):56-9.
[15]车莲鸿.卫生服务空间可达性度量方法与应用领域[J].中国卫生事业管理,2013, 02):88-91.
[16]王法辉,罗卫,程杨.就医便捷度的度量、影响与优化[M]//施迅,王法辉,地理信息技术在公共卫生与健康领域的应用.北京;高等教育出版社.2016:183-209.
[17]DOUGLAS B, MORRIS J, SMITH C, et al. London:Department of Health and Social Security, 1980.
[18]WHITEHEAD M. The Concepts and Principles of Equity and Health[J]. International Journal of Health Services, 1992, 22(3):429-45.
[19]KAWACHI I,SUBRAMANIAN S V, ALMEIDA-FILHO N. A glossary for health inequalities[J]. Journal of Epidemiology and Community Health, 2002, 56(9):647-52.
[20]健康问题社会决定因素委员会,世界卫生组织,2008.
[21]EASTERLIN R A. Does Economic Growth Improve the Human Lot? Some Empirical Evidence A2-DAVID, PAUL A[M]//REDER M W. Nations and Households in Economic Growth:Essays in Honor of Moses Abramovitz. New York; Academic Press. 1974:89-125.
[22]DEATON A, Health, Inequality, and Economic Development[J]. Journal of Economic Literature, 2003, 41(3):113-58.
[23]MCLEOD C B, LAVIS J N, MUSTARD C A, et al. Income Inequality, HouseholdIncome, and Health Status in Canada:A Prospective Cohort Study[J]. American Journal of Public Health, 2003, 93(8):1287-93
[24]HOU F, MYLES J. Neighbourhood Inequality, Relative Deprivation and Self-perceived Health Status[M]//DMSION B A L M A. Ottawa; Statistics Canada, 2004.
[25]JUDGE K, PATERSON I. Poverty, Income Inequality and Health[M]//TREASURY N Z. Treasury Working Paper Series. New Zealand. 2001:64.
[26]O'DONNELLO, DOORSLAER E V, WAGSTAFF A, et al. Washington, D.C.:The World Bank, 2008.
[27]王丽,赵郁馨,张毓辉,et al.卫生服务利用公平性分析方法研究[J].中国卫生经济,2005,24(7):8-10.
[28]SUTTON M. Vertical and horizontal aspects of socio-economic inequity in general practitioner contacts in Scotland Authors[J]. Health Economics, 2002,11(6):537-49.