城市外来人口健康与医疗服务利用行为研究
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摘要
健康是人类生存与发展的基本权利,它不仅是发展的首要目标之一,也对人类发展的其它维度(例如经济发展和教育水平等)具有强大的工具性价值。尽管健康对个人以及社会经济发展的重要意义不言而喻,但在中国,健康一直以来被认为是个人的事情,只有全国性的公共卫生事业才是政府的责任。由于对个人健康权利的不重视,改革开放30多年经济飞速发展的同时,健康、环境等社会指标的发展却远远滞后,甚至出现退化。
经济社会转型过程中的人口健康与医疗卫生问题,单靠医疗机构的努力已经力不从心。首先,病因谱统计结果表明现代疾病是生物、心理、行为及社会因素共同造成的,并不是医学发展能够直接解决的问题。其次,近年来我国不同社会群体之间日益扩大的健康水平和医疗服务利用水平差距已成为我国卫生与社会发展领域一个不容忽视的问题。
现在逐渐引起学界关注但研究相对不足的一个特殊群体是城市外来人口。虽然国内外研究大都证实外来人口具有相对于流入地居民或流出地一般人口较好的健康,但由于城市外来人口在流动过程中经历的各种变化,以及他们在流入城市获得基本公共服务的制度障碍,使得外来人口成为一个健康受损风险极高的群体。而由于外来人口的流动行为也会对其他群体的健康产生影响,因此城市外来人口的健康和医疗卫生问题,表面看是人口空间位移所产生的特殊群体的自身发展问题,实际上还隐含着城乡和区域统筹发展、社会稳定和公平等问题。研究城市外来人口的健康和医疗卫生问题具有突出的现实意义。
本文以上海为例,研究城市外来人口的健康和医疗服务利用行为。上海作为中国经济规模最大的城市,吸引了大规模的外来人口,为上海的经济和社会持续发展提供了源源不断的动力。作为国内最早进入老龄化城市的社会,上海迫切需要推出吸引外来劳动力的相关政策,包括促进外来人口的就业、住房、教育、健康和医疗保障等各方面的政策。以上海为范例,展开对外来人口健康和医疗服务利用行为的研究,具有典型意义。
本文立足于微观个体健康和医疗服务利用影响因素的分析,通过比较上海外来人口和本地居民两个群体,识别独特地影响城市外来人口健康和医疗服务利用行为的因素,以提出有针对性的降低外来人口的健康风险、改善他们的健康状况、消除他们与其他群体之间的健康差距和医疗服务利用差距的公共政策。具体研究内容包括：
第一,通过系统归纳国内外有关城市外来人口健康和医疗服务利用问题的理论模型和经验研究,建立本文的理论分析框架。其中,医疗服务利用行为模型是本文的基础模型,健康的社会决定因素模型用以解释医疗服务利用行为模型所假定的变量关系,行为心理因素与健康的关系理论进一步理解社会因素对健康的作用机制,而人口迁移与健康的理论帮助我们理解外来人口的流动特征与其健康状况变化之间的关系。
第二,通过对历史文献的梳理分析影响城市外来人口健康和医疗服务利用行为的宏观环境和制度因素,包括对外来人口在城市获得基本公共服务造成障碍的户籍、住房、医疗保障等制度。
第三,利用2008年上海外来人口与本地居民健康调查数据,分析影响外来人口和本地居民健康和医疗服务利用行为的因素。在对健康影响因素的研究中,居住条件(包括住房条件和居住区条件)对健康的影响比社会经济状况更显著,而外来人口相对于本地居民明显的居住条件劣势,说明改善外来人口的居住条件是增进外来人口健康的有效政策。并且,重要的不是房屋产权,而是改善住房的简陋和拥挤情况,以及改善外来人口聚居区的社区环境。
第四,在对医疗服务利用影响因素的研究中,医保覆盖率并不是影响外来人口与城市居民就医行为和就医花费差异的显著因素,医疗保险的保障水平才会对外来人口和城市居民的疾病经济负担造成影响。外来人口和本地居民群体内部都存在城乡人口参保类型差异,努力缩小不同类型医保的保障水平差异才是改善外来人口医疗服务利用的有效政策。
第五,外来人口在城市新建立的社会关系网以及与家乡维系的社会关系网对其健康和医疗服务利用的影响机制不同。相对剥夺理论解释前者会对外来人口的健康产生不利影响,后者对外来人口的健康产生有利影响。前者扩大了外来人口在城市获取医疗服务的信息和帮助渠道,会增进外来人口的医疗服务利用,而后者对外来人口使用城市医疗服务具有反效果。这说明促使外来人口融入城市社会的关键是提高其相对社会经济地位,同时构建有益的社会支持网。
Health is a basic right for human development. It is not only one of the primary goals of development, but also has great instrumental value on other dimensions of human development. However, in China, health has always been considered as a personal matter, and only the national public health service is the responsibility of the government. Because the government does not attach importance to personal health rights, the social indicators of development, such as health and environment, have lagged far behind the economic indicators of development, or even degradation during the the reform and opening up30years.
The population health and health care issues during the process of economic and social transition can not only rely on the efforts of medical institutions. First, diseases in modern times are caused by biological, psychological, behavioral and social factors. Second, the exaggerating gaps of health and health care utilization between different social groups in China have become important problems in recent years.
Nowadays researchers gradually give attention to a special group, migrants' health. The internal and international evidence both show that migrants have better health than the general population where they migrated from or migrated to. However, because of the changes migrants experienced during the migration process, as well as the institutional obstacles of access to urban public service, migrants are always at high risks of health impairment. On the other hand, the migration behavior could affect other population groups. The health and health care issues of migrants, not only relate to the development of a special group caused by geographic movement, but also imply balancing urban and rural development, social stability and social equity. Studying migrants'health and health care issues has important practical significance.
This dissertation studies the health and health care utilization problems of migrants, taking Shanghai as an example. Because of the rapid economic and social development, Shanghai has absorbed a great number of migrants. And as the first mainland city entering aging societies, Shanghai must continuously absorb migrant labour force. Therefore, Shanghai has urgent need to introduce employment, housing, education, health care and medical insurance policies for migrant group.
This dissertation studies the determinants of health and health care utilization of micro individuals. By comparing the migrant and local native groups, we identify unique factors which affect migrants'health and health care utilization, but not the natives. Then, we propose relevant suggestions aiming at reducing migrants'health risks, improving their health status, and eliminating the health and health care utilization disparities between migrant and native groups. The specific objectives include:
First, by systematically summarizing theoretical models and empirical studies on health and health care utilization, we establish the theoretical framework of our research. The behavioral model of health care utilization is our fundamental model, which defines variables and assumes the relationships between different variables. The social determinants of health explain the relations supposing by the behavioral model. The theories about the relations between behavioral and psychological factors and health further explain the mechanism between social determinants and health. The theories about migration and health help us understanding the relations between mobility characteristics and migrants'health status.
Second, by researching historial documents, this dissertation analyzes the macro environment and institutional factors which influence miagrans'health and health care utilization, including the systems of household registration, housing, employment and medical insurance.
Third, using the2008health survey of Shanghai migrants and natives, we studies the influence factors of health and health care utilization behavior. About the determinants of health, living conditions, including housing and neighbourhood environment, have more significance than socio-economic status. Because migrants' living conditions are inferior comparing to the natives, it is important to draft public policies aiming at improving migrants'living conditions, especially shabby and crowded housing and neighbourhood conditions.
Fourth, about the determinants of health care utilization, health insurance coverage is not a significant factor. Instead, the security level of health insurance plays an importance role in the economic burden of health and diseases. The migrant and native groups have very different types of health insurance. It is important to narrow down the gaps of security levels between different types of health insurance.
Fifth, migrants'local and trans-local social networks have different influences on their health status and health care utilization behavior. The relative deprivation theory explains that migtants'local ties in the cities would make negative effects on their health, but their trans-local ties in the hometowns would benefit their health. On the contrary, migrants'local ties would promote their utilization of health care services because local ties help expanding migrants'access to health care services and providing information channels, while trans-local ties would hinder migrant' using health care services. This finding implies that the key to promoting migrants' integration into the urban societies are improving their relative socioeconomic status and helping migrants building beneficial social networks.
经济社会转型过程中的人口健康与医疗卫生问题,单靠医疗机构的努力已经力不从心。首先,病因谱统计结果表明现代疾病是生物、心理、行为及社会因素共同造成的,并不是医学发展能够直接解决的问题。其次,近年来我国不同社会群体之间日益扩大的健康水平和医疗服务利用水平差距已成为我国卫生与社会发展领域一个不容忽视的问题。
现在逐渐引起学界关注但研究相对不足的一个特殊群体是城市外来人口。虽然国内外研究大都证实外来人口具有相对于流入地居民或流出地一般人口较好的健康,但由于城市外来人口在流动过程中经历的各种变化,以及他们在流入城市获得基本公共服务的制度障碍,使得外来人口成为一个健康受损风险极高的群体。而由于外来人口的流动行为也会对其他群体的健康产生影响,因此城市外来人口的健康和医疗卫生问题,表面看是人口空间位移所产生的特殊群体的自身发展问题,实际上还隐含着城乡和区域统筹发展、社会稳定和公平等问题。研究城市外来人口的健康和医疗卫生问题具有突出的现实意义。
本文以上海为例,研究城市外来人口的健康和医疗服务利用行为。上海作为中国经济规模最大的城市,吸引了大规模的外来人口,为上海的经济和社会持续发展提供了源源不断的动力。作为国内最早进入老龄化城市的社会,上海迫切需要推出吸引外来劳动力的相关政策,包括促进外来人口的就业、住房、教育、健康和医疗保障等各方面的政策。以上海为范例,展开对外来人口健康和医疗服务利用行为的研究,具有典型意义。
本文立足于微观个体健康和医疗服务利用影响因素的分析,通过比较上海外来人口和本地居民两个群体,识别独特地影响城市外来人口健康和医疗服务利用行为的因素,以提出有针对性的降低外来人口的健康风险、改善他们的健康状况、消除他们与其他群体之间的健康差距和医疗服务利用差距的公共政策。具体研究内容包括：
第一,通过系统归纳国内外有关城市外来人口健康和医疗服务利用问题的理论模型和经验研究,建立本文的理论分析框架。其中,医疗服务利用行为模型是本文的基础模型,健康的社会决定因素模型用以解释医疗服务利用行为模型所假定的变量关系,行为心理因素与健康的关系理论进一步理解社会因素对健康的作用机制,而人口迁移与健康的理论帮助我们理解外来人口的流动特征与其健康状况变化之间的关系。
第二,通过对历史文献的梳理分析影响城市外来人口健康和医疗服务利用行为的宏观环境和制度因素,包括对外来人口在城市获得基本公共服务造成障碍的户籍、住房、医疗保障等制度。
第三,利用2008年上海外来人口与本地居民健康调查数据,分析影响外来人口和本地居民健康和医疗服务利用行为的因素。在对健康影响因素的研究中,居住条件(包括住房条件和居住区条件)对健康的影响比社会经济状况更显著,而外来人口相对于本地居民明显的居住条件劣势,说明改善外来人口的居住条件是增进外来人口健康的有效政策。并且,重要的不是房屋产权,而是改善住房的简陋和拥挤情况,以及改善外来人口聚居区的社区环境。
第四,在对医疗服务利用影响因素的研究中,医保覆盖率并不是影响外来人口与城市居民就医行为和就医花费差异的显著因素,医疗保险的保障水平才会对外来人口和城市居民的疾病经济负担造成影响。外来人口和本地居民群体内部都存在城乡人口参保类型差异,努力缩小不同类型医保的保障水平差异才是改善外来人口医疗服务利用的有效政策。
第五,外来人口在城市新建立的社会关系网以及与家乡维系的社会关系网对其健康和医疗服务利用的影响机制不同。相对剥夺理论解释前者会对外来人口的健康产生不利影响,后者对外来人口的健康产生有利影响。前者扩大了外来人口在城市获取医疗服务的信息和帮助渠道,会增进外来人口的医疗服务利用,而后者对外来人口使用城市医疗服务具有反效果。这说明促使外来人口融入城市社会的关键是提高其相对社会经济地位,同时构建有益的社会支持网。
Health is a basic right for human development. It is not only one of the primary goals of development, but also has great instrumental value on other dimensions of human development. However, in China, health has always been considered as a personal matter, and only the national public health service is the responsibility of the government. Because the government does not attach importance to personal health rights, the social indicators of development, such as health and environment, have lagged far behind the economic indicators of development, or even degradation during the the reform and opening up30years.
The population health and health care issues during the process of economic and social transition can not only rely on the efforts of medical institutions. First, diseases in modern times are caused by biological, psychological, behavioral and social factors. Second, the exaggerating gaps of health and health care utilization between different social groups in China have become important problems in recent years.
Nowadays researchers gradually give attention to a special group, migrants' health. The internal and international evidence both show that migrants have better health than the general population where they migrated from or migrated to. However, because of the changes migrants experienced during the migration process, as well as the institutional obstacles of access to urban public service, migrants are always at high risks of health impairment. On the other hand, the migration behavior could affect other population groups. The health and health care issues of migrants, not only relate to the development of a special group caused by geographic movement, but also imply balancing urban and rural development, social stability and social equity. Studying migrants'health and health care issues has important practical significance.
This dissertation studies the health and health care utilization problems of migrants, taking Shanghai as an example. Because of the rapid economic and social development, Shanghai has absorbed a great number of migrants. And as the first mainland city entering aging societies, Shanghai must continuously absorb migrant labour force. Therefore, Shanghai has urgent need to introduce employment, housing, education, health care and medical insurance policies for migrant group.
This dissertation studies the determinants of health and health care utilization of micro individuals. By comparing the migrant and local native groups, we identify unique factors which affect migrants'health and health care utilization, but not the natives. Then, we propose relevant suggestions aiming at reducing migrants'health risks, improving their health status, and eliminating the health and health care utilization disparities between migrant and native groups. The specific objectives include:
First, by systematically summarizing theoretical models and empirical studies on health and health care utilization, we establish the theoretical framework of our research. The behavioral model of health care utilization is our fundamental model, which defines variables and assumes the relationships between different variables. The social determinants of health explain the relations supposing by the behavioral model. The theories about the relations between behavioral and psychological factors and health further explain the mechanism between social determinants and health. The theories about migration and health help us understanding the relations between mobility characteristics and migrants'health status.
Second, by researching historial documents, this dissertation analyzes the macro environment and institutional factors which influence miagrans'health and health care utilization, including the systems of household registration, housing, employment and medical insurance.
Third, using the2008health survey of Shanghai migrants and natives, we studies the influence factors of health and health care utilization behavior. About the determinants of health, living conditions, including housing and neighbourhood environment, have more significance than socio-economic status. Because migrants' living conditions are inferior comparing to the natives, it is important to draft public policies aiming at improving migrants'living conditions, especially shabby and crowded housing and neighbourhood conditions.
Fourth, about the determinants of health care utilization, health insurance coverage is not a significant factor. Instead, the security level of health insurance plays an importance role in the economic burden of health and diseases. The migrant and native groups have very different types of health insurance. It is important to narrow down the gaps of security levels between different types of health insurance.
Fifth, migrants'local and trans-local social networks have different influences on their health status and health care utilization behavior. The relative deprivation theory explains that migtants'local ties in the cities would make negative effects on their health, but their trans-local ties in the hometowns would benefit their health. On the contrary, migrants'local ties would promote their utilization of health care services because local ties help expanding migrants'access to health care services and providing information channels, while trans-local ties would hinder migrant' using health care services. This finding implies that the key to promoting migrants' integration into the urban societies are improving their relative socioeconomic status and helping migrants building beneficial social networks.
引文
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