农村基本医疗卫生服务购买策略研究
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摘要
研究背景
‘人人享有基本医疗卫生服务”被确立为中国新一轮医改的战略目标。基本医疗卫生服务包含公共卫生服务和基本医疗服务,是卫生系统的基础层次和核心部分,其公平性、效率和质量与居民的健康福利息息相关,对卫生系统整体绩效的优化有着重要影响。
农村卫生工作是我国卫生工作的重点,却也是薄弱环节。长期以来,对农村基本医疗卫生服务及其重要载体——乡镇卫生院和村卫生室的投入不足,更为严重的是,投入的资金难以得到有效利用。医疗卫生服务领域存在着广泛的市场失灵和政府失灵,而资源配置不合理,服务需求不合理,激励机制不合理则加重了问题的严重性,导致基本医疗卫生服务的低效率、低质量和浪费,严重影响了政府及公共投入的有效性,也阻碍了基本医疗卫生服务的可及性。因此在加大投入的同时,需要寻求更加有效的策略以加强基本医疗卫生的公平可及性,保障服务供给的效率和质量,以提高农村地区卫生系统的绩效,改善农村居民的健康结果。
在我国,政府投入和基本医疗保障是对基层医疗卫生机构及其所提供服务的主要补偿渠道。公共资金投入卫生服务主要有两种途径,一是政府利用一般性政府收入直接向自己下设的卫生服务提供者下拨预算；二是独立的购买机构或角色代表全体或特定群体向供方购买卫生服务。当前,国际卫生服务领域改革过程中出现了一个重要的趋势：政府重新定位为决策者和监督者,而卫生服务的提供及管理形式从等级性的集权方式(上述第一种方式)向基于服务购买和提供相分离的模式(上述第二种方式)转变。但是即使在第二种模式下,如果只是进行被动的事后付款而不采取具有战略性的购买措施,仍然不能解决卫生系统绩效低下的问题。因此,采用购买与提供职能分离的、且具有“战略性”的服务购买模式被认为是改善系统绩效的重要政策工具,成为全世界普遍关注的研究和实践命题。
医改近期重点任务是“保基本、强基层、建机制”,在医改方案中体现了医疗卫生服务购买与提供分离的理念以及战略性购买的基本构想。然而,我国对基本医疗卫生服务,尤其在农村地区的购买实践尚处试点起步阶段,关于医疗卫生服务购买的研究,也主要停留在概念导入阶段,对医疗卫生服务购买体系现状的认识,购买策略的设计研究,以及购买策略实施及效果评价研究都十分有限。在新医改背景下,从保障基本医疗卫生服务,提高卫生系统绩效目的出发,加紧对基本医疗卫生服务购买体系的研究则十分必要,尤其对基础薄弱、基层弱化的农村地区来说,在供方竞争有限、能力和供给不足的情况下,研究如何利用政府投入和医疗保险基金,战略性地发展服务购买策略,优先购买哪些服务,采取怎样的具体购买机制,如何改变购买方对供方支付方式的设定,才能最终实现资源的合理配置,对供方形成有效的激励,从而提高卫生服务的可及性、效率和质量,显得尤为重要。
研究目的
本研究主要通过规范性研究理清卫生服务购买体系中各方的利益关系和互动机制,形成服务购买策略研制和设计的基本思路框架,基于案例研究对理论进行应用,从农村基本医疗卫生系统绩效现况和主要问题着手,从服务购买角度进行问题诊断和根源分析,在此基础上进行战略性服务购买策略的系统设计,特别是购买方对基层医疗卫生机构所提供的基本医疗卫生服务支付策略的设计,并对购买策略改革干预实施情况进行监测和评价。
研究方法
本文在研究过程中主要应用了三个理论框架,即以政策循环理论指导研究的总体思路,从卫生系统问题出发,在政治环境、经济条件和社会价值的背景下,经历问题诊断、政策设计、政治决策、政策实施和政策评价的环路；以卫生发展与改革理论框架指导分析影响卫生系统绩效及中间指标的问题根源,并与卫生服务购买要素相结合构建基本医疗卫生服务的购买策略研制思路；以结果链逻辑框架指导对农村基本医疗卫生服务购买策略,尤其是福利包调整和支付方式改革策略的实施和近期结果的监测与评价。
运用案例研究法,实现基于现实的理论应用,以既有代表性又有改革基础的宁夏自治区农村地区为案例,加强研究的可借鉴性和示范意义。选取该区两个县(海原县和盐池县),基于其卫生系统基线情况、问题及根源,在理论指导下发展出基本医疗卫生服务战略性购买策略,特别是支付方式改革策略,并通过对照的设立,对购买策略改革实施情况及效果进行监测和评价。
研究所需资料的调查方法包括：文献回顾、入户调查、机构调查和定性访谈。经文献回顾掌握国内外卫生服务购买理论与实践进展及调查地区农村卫生系统绩效干预前后情况；于2009年2月份别进行入户调查和机构调查,以了解宁夏农村居民卫生服务需求和利用及基层医疗卫生机构、人员及业务开展基线情况；基于关键知情人和焦点组等定性访谈获知宁夏农村地区基本医疗卫生系统现状,问题及原因,各利益相关方的利益诉求,及购买策略实施后其行为变化、利益得失和主观看法与评价。
此外,文中还运用PETS分析法对支付方式改革设计进行可行性分析,运用倍差法(Difference-in-difference)对购买策略改革的效果进行初步评价。
研究结果
1.对战略性购买理论和实践经验的总结：战略性购买以改善卫生系统整体绩效为目标,强调满足公众的健康需要,追求服务的成本效果,注重供方激励机制的重塑,提倡竞争机制的运用和政府的宏观监管,以此在购买前战略性地做出“购买什么,如何购买,向谁购买”的决策并加以实施。在战略性购买体系中至少存在四个角色定位及三个委托代理关系,即需方委托购买方实现自身需要,政府委托购买方合理配置资源,购买方委托供方提供适宜服务,这些关系需要依靠相关手段和机制维系,使得代理方按照委托方的需要和目标做出行为。
2.将购买理论与卫生系统模型相结合,形成服务购买策略研制思路：战略性卫生服务购买策略包括从购买方角度提出的“购买什么、如何购买、向谁购买”的核心策略,主要涉及购买方与供方之间的关系；以及从整个卫生系统角度提出的针对组织和制度环境,作用于购买方、需方、供方组织以及购买方与需方、购买方与政府之间的关系,以确保战略性购买核心策略得以实施的支持保障策略。利用卫生发展与改革理论框架可以建立起购买策略与卫生系统绩效的联系,并系统地寻找战略性购买策略,运用此框架中的筹资、支付和组织阀门的相关政策工具构建购买核心策略,在组织、规制、行为阀门的相关政策工具基础上形成购买支持保障策略。
3.应用理论结合实证分析农村基本医疗卫生绩效问题及根源：居民健康需要的重点在公共卫生和基本医疗,但实证数据显示基本医疗卫生服务可及性差、效率低下、质量不佳,基层医疗卫生机构特别是村卫生室能力薄弱、供给不足。服务购买与服务提供功能的分离已存在于这些体系中,但处于被动购买状态,购买策略不具战略性。目前的问题主要由购买核心策略的组合不当引起,即购买内容、购买方式和购买对象不恰当,问题根源是购买方对需方代表性不足、购买方对供方调控机制薄弱以及政府在服务购买过程中监管有限,即购买体系和机制的不健全不完善。
4.根据购买策略研制思路,对农村基本医疗卫生服务购买策略进行改进设计细化：从购买方(地方政府、卫生行政部门、新农合机构)角度设计了一系列购买核心策略,包括：整合公共卫生和新农合基本医疗筹资、调整福利包范围和报销比例的筹资策略,改变支付方式、提高供方收入、支付与绩效挂钩的支付策略,并在支付策略基础上发展了乡村一体化和引入竞争机制的组织策略。从系统角度,提出由政府加以实施或监管的明确乡村两级定位、建立居民监管问责机制、开展群众健康教育、提高供方专业及管理能力等购买支持保障策略。
5.对购买体系核心机制支付方式及实施方案进行详细设计：以乡村整体为支付对象,采用复合型支付方式以权衡农村基本医疗卫生服务多重目标,以人头费预付公共卫生服务及基本医疗门诊服务,引导供方节约服务成本,实现效率目标；按项目支付村医门诊服务的诊疗费和出诊费,促进村医提供更多服务,增强服务可及性；同时按绩效支付预算的30%,以提高供方服务质量。根据设计,上述支付方式下经济激励机制的设置可衍生出“乡村一体化”、“竞争机制”等组织变革,进一步优化系统资源的配置。此外,本文在构建支付方式中的激励因素作用机制模型基础上,提出支付方式必须与其他规制、管理手段相互协同和促进,应当建立管理信息系统、制定诊疗规范及制度、制定监测评价系统并加强供方内部管理。
6.运用结果链逻辑框架对购买策略改革干预的监测评价：所设计的购买策略已在宁夏自治区两个试点县启动实施,第一阶段聚焦于福利包的调整和支付制度的改革。虽然项目还在试点初期,尚缺乏有关干预措施效果及影响的明确证据,但基于实证,各项试点工作在稳步推进中,各方反应基本良好,预期行为改变发生。基层门诊服务利用大幅上升,两试点县基层医疗机构2010年新农合门诊量分别是2009年同期2.5倍和4.0倍,且试点县乡、村两级人均就诊次数增加量分别高于对照县；资源利用效率有所提升,两试点县新农合住院率下降,新农合门诊就诊率则分别从年人均0.99次和0.41次上升至2.61次和1.43次,试点县内由新农合支付的乡村两级门诊服务中,超过或接近一半发生在村一级,基本医疗服务下沉效果显著,乡村两级机构次均门诊费用呈下降趋势,且实施支付制度干预的乡镇卫生院次均门诊费用较对照乡镇卫生院下降得多；项目进展总体趋向与设计相符。
政策建议
1.在农村地区进行卫生服务公共资金投入时,以系统整体绩效改善为目标,逐步引入“战略性购买”的理念和策略。即将卫生服务的购买功能与提供功能适度分离,实施以公众需要为基础、成本效益理念、竞争理念、契约理念、绩效评估为核心的目标型管理,科学发展“购买什么、怎么购买、向谁购买”的购买核心策略以及作用于组织、制度,确保核心策略顺利实施的购买支持保障策略。
2.重视居民预防保健和常见病、多发病及慢性病诊治的需要,基于此类服务的成本效果特点,调整农村的医疗卫生福利包,即购买保障的范围和水平,从以前关注重大疾病／住院服务向公共卫生和基本医疗服务进行战略性调整,提高新农合门诊服务,尤其是基层机构报销比,用经济激励机制调控需方的需求和服务利用行为。
3.整合公共卫生和基本医疗服务筹资。现阶段可将政府下拨的公共卫生经费与新农合补助及居民缴付的参合资金进行整合,从中划拨出基本医疗卫生服务经费,并在对供方进行支付时,与公共卫生服务和基本医疗服务的整体绩效挂钩,以此实现资金整合的效果,提高购买方对供方的调控力,加强资金的使用效率。
4.为平衡卫生服务可及性、公平性、效率、质量等目标,建议采用复合型支付方式。对基本医疗卫生服务,改革原有单纯按项目付费机制,采用按人头付费、按项目付费、按绩效支付的协同方式,以促使供方在服务量、效率和质量方面的同步提升。
5.建议通过适当的薪酬、合理的职能定位、诊疗规范以及强化培训,引导并保障供方人员的保留和生产力的提高,向卫生专业人员提供适当的激励以解决西部农村村级卫生人员不足、生产力低下的问题。
6.通过经济激励机制的设计,给予乡镇卫生院对村卫生室收入的考核分配权和结余留用权,强调卫生院对村卫生室绩效的连带责任,并与卫生院的绩效收入挂钩,以调动乡镇卫生院的积极性,落实乡镇卫生院对村卫生室的管理,推进“乡村一体化”,从而优化乡村资源配置,规范服务行为,提高村医服务能力,实现卫生服务的下沉以及效率的提升。
7.在基本医疗卫生服务购买过程中,建立需方参与机制。可以通过建立居民管理小组、监管理事会等形式,充分发挥居民在购买决策、绩效考核、监督管理等方面的话语权,强化购买方对需方的代表性。同时加强对居民的健康教育,帮助居民正确表达其健康需要。
8.中央和上级政府对地方政府及购买机构下放购买决策权和行动权,以增强购买方对需方的反应性。地方政府及购买机构必须加强自身对卫生服务购买的进一步理解、信息收集和分析、与供方谈判协商、对供方绩效监测评价等能力以及公信力的建设。
9.基本医疗卫生服务的提供与保障,必须坚持政府主导与市场机制相结合的原则,强调政府在服务购买中的监管。中央政府和省级政府以战略性购买政策方向和法规框架的确立,信息收集和利用,各方利益的平衡为主要干预与规制范畴,需要特别加强对地方购买机构的监督和考核；同时作为公立机构所有者,在目前阶段还要通过“补供方”形式加强对基层医疗卫生机构基础设施和人力资源的投入,加强供方的能力建设。
10.战略性服务购买的每个环节都离不开对供方日常卫生服务信息的收集和处理,信息的需求量以及处理方式已完全不同于传统的被动性购买方式下对信息的要求,因此必须加强管理信息系统的投入和建设。此外,还必须通过明确供方定位、制定诊疗规范、提高供方能力和自主性、加强供方的职业道德教育、对患者实施健康教育等一系列作用于供需双方的管理和规范等支持保障策略,来促成购买核心策略的实施,并放大服务购买的效应。
11.对本研究所涉及的相关购买策略进行严格而全面的监测和评估,其他卫生服务购买干预项目亦如此。
研究总结
本文引入卫生服务战略性购买理念,在对购买相关理论实践总结基础上,与卫生系统模型结合提出战略性购买策略的研制思路,并通过案例在现实中对理论进行应用,从服务购买角度对宁夏地区基本医疗卫生系统问题进行分析,之后对具体的购买策略进行改进设计,并在实践中进行验证。本研究中所呈现出的基本医疗卫生服务购买理念和策略研制思路、所设计的购买策略及支付方式改革策略具有可扩展性和可借鉴性,对其他地区尤其是西部农村地区具有示范意义。
Background
"Equitable and universal access to basic health care for all" is established as the strategic goal of the new health reform plan in China. The Basic health care sector, comprising public health care and basic medical care, is regarded as the foundation as well as the core of the whole health system. The equity, efficiency and quality of the basic health care sector is closely linked to the population's health and welfare, and also count for the optimization of the performance of the health system.
Rural health is the key of the health system in China. However, the basic health care and its delivery system, the township health center and village clinics, in rural area suffered inadequate funding for a long time. More seriously, the invested funds were not effectively and efficiently used. Market failure and government failure prevailed in the health sector, while the irrational use of health resources, the unreasonable health demands as well as the perverse incentives made things worse that resulted in inefficiency, low quality of basic health care and waste of resources. Therefore, the effective strategies to promote the access and to enhance equity, efficiency and quality of the basic health care must be sought along with the fund increases to drive the health system change well and improve the health outcomes of the rural population.
In China, the primary health facilities and its provided services are funded through two main channels:government fund and health insurance fund. Generally, the public fund goes in two ways:one is direct subsidies or budgets to the public facilities, the other is an independent purchasing role buy the health services for all or specific population. Recently, there is a common trend in health sector reform worldwide, which is a move from hierarchical and integrated forms of service delivery and finance towards devolved models based upon the separation of the responsibility for purchasing services from the responsibility for providing them. However, the passive exercise of purchasing that involves mere post-reimbursement of expenses to providers is far from enough. Hence, the strategic purchasing based on purchaser-provider split is promoted as a key policy instrument to improve health system performance and becomes a heated topic for research and practice around the world.
The priority of health care reform agenda is "to ensure basic health care, to strengthen primary health facilities and to establish mechanisms to achieve the goal", with the idea of purchaser-provider split and strategic purchasing written in the reform plan. However, the practice of purchasing of basic health care, particularly in rural areas, is in its very first stage while the study on purchasing is still in the initial process of introduction of concepts. There are limited researches on the status quo of purchasing system, design of purchasing strategies, say nothing of the evaluation of purchasing interventions in China. Thus in the context of the new health care reform, it is essential to conduct studies on purchasing system of basic health care, especially in rural areas, to develop the purchasing strategies on what to buy, how to pay and from whom to buy to achieve rational use of resources and effective motivation for providers in the condition of limited competition and low capability of providers, making the full use of the government fund and the medical insurance fund to fulfill the ultimate goal of health system.
Objectives
Using normative study to understand the relationships between different actors in health care purchasing system and the interactive mechanisms among the relationships, based on which the approach framework to design and develop purchasing strategies is established. Applying theories into practice through case study:to diagnose the main problems of basic health care system performance in rural areas and find the root courses from the perspective of purchasing, to design series of purchasing strategies, especially the payment methods and then monitor and evaluate the purchasing interventions after implementation.
Methods
Employ three theoretical frameworks. The policy cycle framework was adopted as the general approach of the research, starting from the problem definition, through diagnosing, design, political decision, implementation and ending with evaluation; the development and reform framework was used as the method to find the causes of the problems and to develop the design approach framework of the purchasing strategies; the result chain framework was taken to guide the monitoring and evaluation of the purchasing interventions.
Case study was conducted to make application of theories and rationales. Rural area in the Ningxia Hui Autonomous Region was selected as a case for its representativeness and reform foundation in advance. Two counties in Ningxia (Haiyuan and Yanchi) were investigated in detail, and then the design, monitoring and evaluation of the strategic purchasing policies are developed accordingly.
Some investigation methods were used. Literature review was applied to realize the rationales and practices of health care purchasing home and abroad and the secondhand data of system performance before and after intervention; household survey and facility survey were conducted in February 2009 to attain the information about health care demand and utilization of the population as well as situations of the primary facilities, health workers and health care operations; qualitative interviews were intended to know about problems and reasons, stakeholders'appeals and their views and appraisals after interventions implementation.
Furthermore, PETS analysis and difference-in difference method were driven to verify feasibility and evaluate the effect and impact of the interventions respectively.
Results
1. Summary of rationales and practices of strategic purchasing:Aimed at improving the health system performance, strategic purchasing involved the realization of public's health need, emphasis on cost-effective services, reconstruction of incentives for providers, encouragement in competition and requirement of government stewardship. Proactive decisions were made about which health care services should be purchased, how and from whom. There were at least four roles and three principal-agent relationships inside the purchasing systems:the purchaser acted as the consumers'agent in the purchase of health care services on their behalf; the purchaser employed a providers to deliver the appropriate mix of health care, of acceptable quality, at an agreed price; the purchaser acted as agent for the government or state to rationally allocate health resources. In order to make the agent acts well, series of tools and mechanisms must be adopted to ensure the relationships.
2. Combining the purchasing theories with the health system model to produce the approach framework for developing heath care purchasing strategies:Purchasing strategies comprised the "core policies" deciding which interventions should be purchased, how they should be purchased and from whom from the purchaser's standpoint as well as the "supporting and ensuring policies" mainly aiming at the organization and institution environment from the perspective of the health system. According to the health development and reform framework, instruments towards the financing, payment and part of the organization knobs could be used to establish the core policies of purchasing primarily acting on the relationship between purchaser and provider; other organizational, regulation and behavioral instruments were proposed to work as the supporting and ensuring policies.
3. Applying theories on empirical case to define and diagnose basic health care problems in rural area:public health care and basic medical care are the key points for rural population's health need, however empirical data showed that the accessibility, efficiency and quality of basic health care were low while the primary health facilities, particularly the village clinics were incapable and short of supply. Purchaser-provider split already existed in the system; however, the purchasing was in a passive form. The main reasons for the problems were the inappropriate mix of core purchasing policies, and the root courses were based on the purchaser's insufficient representativeness for the population, poor mechanisms for the purchaser to control providers and limited stewardship of the government.
4. According to the approach framework for developing heath care purchasing strategies to design the improved purchasing strategies for the rural area:core policies implemented by the purchasers (the local government, the health department and the NCMS office) including financial strategies to integrate public health care fund with NCMS fund, adjust the scope and reimbursement rate of benefit package; payment strategies to change the payment method, enhance provider's income and pay for performance; organizational strategies which were derived from the payment strategies to integrate the township and village delivery system and to introduce competition. Besides, defining the roles of the township and village providers, establishing mechanisms for the residents to participate and monitor the purchasing processes, launching health education as well as training to promote the specialty and management competence of providers were projected to act as the supporting and ensuring policies.
5. Developing the payment methods as core mechanism in details:blended payment methods acted on the entire township (including the township health center and all the village clinics) were taken to trade off the multiple objectives of the basic health care, prepaid capitation of the public health care and basic outpatient care targeting efficiency, fee-for-service of medical fee per visit enhancing accessibility, and pay-for-performance of the reserved 30% budget improving service quality. Based on the design, integration of township health center and village clinics and competition may emerge in the context of changed incentives, further optimize the resource allocation. A model of the mechanism of action of the financial incentives among the payment methods was produced and accordingly, financial incentives have to be cooperated and promoted mutually with other regulation and management tools. So MIS, protocols, monitoring and quality assurance system and the internal management of providers must be well developed.
6. Monitoring and evaluating the purchasing interventions with the guide of results chain:the designed strategies have been implemented in the two pilot counties, mainly focused on the adjustment of benefit package and reform of payment system in the first phase. Though the pilot was still in its initial stage and there was lack of clear and definite evidences of the effects and impacts, some positive phenomenon were witnessed:intended behavioral changes of providers and demanders appeared, utilization of outpatient services in primary facilities increased rapidly and dramatically, efficiency of resource use was seen improved. Thus the progress of the project was in line.
Suggestions
1. To introduce "strategic purchasing" when public fund is invested into the health care in rural areas to improve the system performance.
2. To adjust the benefit package to fulfill populations'needs for preventive health care and medical care of common diseases and chronic diseases.
3. To integrate the public health care fund and basic medical care fund (usually NCMS fund) sources together to enhance purchaser's power over providers.
4. To adopt blended payment methods to balance the multiple goals of health care to achieve accessibility, equity, efficiency and quality. Change the payment to primary health facilities for basic health care form pure fee-for-service method to combined capitation, fee-for-service and pay-for-performance.
5. To offer proper level of income, rational definition of the provider role, reasonable norms and protocols and intense trainings to providers to solve the problem of insufficient human resources and low productivity.
6. To make use of financial incentive structures to promote the integration of township and village providers, for example, the township health center is permitted to share the village clinic's residual or takes responsibility of the performance of the latter which is also related to its own revenue.
7. To establish the population participation mechanism such as citizens'juries or purchasing boards to improve the agency function of the purchaser.
8. To devolve the right of decision making and action towards lower-level, such as local government and local medical insurance organization, while the purchasers strengthen their capacity and credibility to reinforce the reactiveness of purchasing.
9. To persist in government's domination in the purchasing through stewardship and scrutiny and preserve government funding in the infrastructures and human resources of the public providers.
10. To lay great efforts on construction of management information system to support the process of purchasing and to integrate other management and regulations such as provider positioning, clinical guidelines constitution, increasing provider capability and autonomy, provider ethics training and demander health education, with the core purchasing strategies.
11. To carry out rigorous and comprehensive monitoring and evaluation of the designed interventions involved in this research and so is for other purchasing programs.
Summary
This study introduced the concept of strategic purchasing of health care for the first time. Based on the summary of purchasing theories and the model of health system, an approach framework for designing and developing purchasing strategies was established. Then theories and the conceptual framework were put into practice through a case study. The problems of the health system in Ningxia rural area was defined and diagnosed form the purchasing perspective, the concrete purchasing strategies and policies were then developed and the results were validated in the real world. The idea of strategic purchasing, the approach to produce purchasing strategies and the specific purchasing strategies and payment methods developed in this study can be learned, extended and generalized, as a demonstration for other places, the western rural areas in particular.
‘人人享有基本医疗卫生服务”被确立为中国新一轮医改的战略目标。基本医疗卫生服务包含公共卫生服务和基本医疗服务,是卫生系统的基础层次和核心部分,其公平性、效率和质量与居民的健康福利息息相关,对卫生系统整体绩效的优化有着重要影响。
农村卫生工作是我国卫生工作的重点,却也是薄弱环节。长期以来,对农村基本医疗卫生服务及其重要载体——乡镇卫生院和村卫生室的投入不足,更为严重的是,投入的资金难以得到有效利用。医疗卫生服务领域存在着广泛的市场失灵和政府失灵,而资源配置不合理,服务需求不合理,激励机制不合理则加重了问题的严重性,导致基本医疗卫生服务的低效率、低质量和浪费,严重影响了政府及公共投入的有效性,也阻碍了基本医疗卫生服务的可及性。因此在加大投入的同时,需要寻求更加有效的策略以加强基本医疗卫生的公平可及性,保障服务供给的效率和质量,以提高农村地区卫生系统的绩效,改善农村居民的健康结果。
在我国,政府投入和基本医疗保障是对基层医疗卫生机构及其所提供服务的主要补偿渠道。公共资金投入卫生服务主要有两种途径,一是政府利用一般性政府收入直接向自己下设的卫生服务提供者下拨预算；二是独立的购买机构或角色代表全体或特定群体向供方购买卫生服务。当前,国际卫生服务领域改革过程中出现了一个重要的趋势：政府重新定位为决策者和监督者,而卫生服务的提供及管理形式从等级性的集权方式(上述第一种方式)向基于服务购买和提供相分离的模式(上述第二种方式)转变。但是即使在第二种模式下,如果只是进行被动的事后付款而不采取具有战略性的购买措施,仍然不能解决卫生系统绩效低下的问题。因此,采用购买与提供职能分离的、且具有“战略性”的服务购买模式被认为是改善系统绩效的重要政策工具,成为全世界普遍关注的研究和实践命题。
医改近期重点任务是“保基本、强基层、建机制”,在医改方案中体现了医疗卫生服务购买与提供分离的理念以及战略性购买的基本构想。然而,我国对基本医疗卫生服务,尤其在农村地区的购买实践尚处试点起步阶段,关于医疗卫生服务购买的研究,也主要停留在概念导入阶段,对医疗卫生服务购买体系现状的认识,购买策略的设计研究,以及购买策略实施及效果评价研究都十分有限。在新医改背景下,从保障基本医疗卫生服务,提高卫生系统绩效目的出发,加紧对基本医疗卫生服务购买体系的研究则十分必要,尤其对基础薄弱、基层弱化的农村地区来说,在供方竞争有限、能力和供给不足的情况下,研究如何利用政府投入和医疗保险基金,战略性地发展服务购买策略,优先购买哪些服务,采取怎样的具体购买机制,如何改变购买方对供方支付方式的设定,才能最终实现资源的合理配置,对供方形成有效的激励,从而提高卫生服务的可及性、效率和质量,显得尤为重要。
研究目的
本研究主要通过规范性研究理清卫生服务购买体系中各方的利益关系和互动机制,形成服务购买策略研制和设计的基本思路框架,基于案例研究对理论进行应用,从农村基本医疗卫生系统绩效现况和主要问题着手,从服务购买角度进行问题诊断和根源分析,在此基础上进行战略性服务购买策略的系统设计,特别是购买方对基层医疗卫生机构所提供的基本医疗卫生服务支付策略的设计,并对购买策略改革干预实施情况进行监测和评价。
研究方法
本文在研究过程中主要应用了三个理论框架,即以政策循环理论指导研究的总体思路,从卫生系统问题出发,在政治环境、经济条件和社会价值的背景下,经历问题诊断、政策设计、政治决策、政策实施和政策评价的环路；以卫生发展与改革理论框架指导分析影响卫生系统绩效及中间指标的问题根源,并与卫生服务购买要素相结合构建基本医疗卫生服务的购买策略研制思路；以结果链逻辑框架指导对农村基本医疗卫生服务购买策略,尤其是福利包调整和支付方式改革策略的实施和近期结果的监测与评价。
运用案例研究法,实现基于现实的理论应用,以既有代表性又有改革基础的宁夏自治区农村地区为案例,加强研究的可借鉴性和示范意义。选取该区两个县(海原县和盐池县),基于其卫生系统基线情况、问题及根源,在理论指导下发展出基本医疗卫生服务战略性购买策略,特别是支付方式改革策略,并通过对照的设立,对购买策略改革实施情况及效果进行监测和评价。
研究所需资料的调查方法包括：文献回顾、入户调查、机构调查和定性访谈。经文献回顾掌握国内外卫生服务购买理论与实践进展及调查地区农村卫生系统绩效干预前后情况；于2009年2月份别进行入户调查和机构调查,以了解宁夏农村居民卫生服务需求和利用及基层医疗卫生机构、人员及业务开展基线情况；基于关键知情人和焦点组等定性访谈获知宁夏农村地区基本医疗卫生系统现状,问题及原因,各利益相关方的利益诉求,及购买策略实施后其行为变化、利益得失和主观看法与评价。
此外,文中还运用PETS分析法对支付方式改革设计进行可行性分析,运用倍差法(Difference-in-difference)对购买策略改革的效果进行初步评价。
研究结果
1.对战略性购买理论和实践经验的总结：战略性购买以改善卫生系统整体绩效为目标,强调满足公众的健康需要,追求服务的成本效果,注重供方激励机制的重塑,提倡竞争机制的运用和政府的宏观监管,以此在购买前战略性地做出“购买什么,如何购买,向谁购买”的决策并加以实施。在战略性购买体系中至少存在四个角色定位及三个委托代理关系,即需方委托购买方实现自身需要,政府委托购买方合理配置资源,购买方委托供方提供适宜服务,这些关系需要依靠相关手段和机制维系,使得代理方按照委托方的需要和目标做出行为。
2.将购买理论与卫生系统模型相结合,形成服务购买策略研制思路：战略性卫生服务购买策略包括从购买方角度提出的“购买什么、如何购买、向谁购买”的核心策略,主要涉及购买方与供方之间的关系；以及从整个卫生系统角度提出的针对组织和制度环境,作用于购买方、需方、供方组织以及购买方与需方、购买方与政府之间的关系,以确保战略性购买核心策略得以实施的支持保障策略。利用卫生发展与改革理论框架可以建立起购买策略与卫生系统绩效的联系,并系统地寻找战略性购买策略,运用此框架中的筹资、支付和组织阀门的相关政策工具构建购买核心策略,在组织、规制、行为阀门的相关政策工具基础上形成购买支持保障策略。
3.应用理论结合实证分析农村基本医疗卫生绩效问题及根源：居民健康需要的重点在公共卫生和基本医疗,但实证数据显示基本医疗卫生服务可及性差、效率低下、质量不佳,基层医疗卫生机构特别是村卫生室能力薄弱、供给不足。服务购买与服务提供功能的分离已存在于这些体系中,但处于被动购买状态,购买策略不具战略性。目前的问题主要由购买核心策略的组合不当引起,即购买内容、购买方式和购买对象不恰当,问题根源是购买方对需方代表性不足、购买方对供方调控机制薄弱以及政府在服务购买过程中监管有限,即购买体系和机制的不健全不完善。
4.根据购买策略研制思路,对农村基本医疗卫生服务购买策略进行改进设计细化：从购买方(地方政府、卫生行政部门、新农合机构)角度设计了一系列购买核心策略,包括：整合公共卫生和新农合基本医疗筹资、调整福利包范围和报销比例的筹资策略,改变支付方式、提高供方收入、支付与绩效挂钩的支付策略,并在支付策略基础上发展了乡村一体化和引入竞争机制的组织策略。从系统角度,提出由政府加以实施或监管的明确乡村两级定位、建立居民监管问责机制、开展群众健康教育、提高供方专业及管理能力等购买支持保障策略。
5.对购买体系核心机制支付方式及实施方案进行详细设计：以乡村整体为支付对象,采用复合型支付方式以权衡农村基本医疗卫生服务多重目标,以人头费预付公共卫生服务及基本医疗门诊服务,引导供方节约服务成本,实现效率目标；按项目支付村医门诊服务的诊疗费和出诊费,促进村医提供更多服务,增强服务可及性；同时按绩效支付预算的30%,以提高供方服务质量。根据设计,上述支付方式下经济激励机制的设置可衍生出“乡村一体化”、“竞争机制”等组织变革,进一步优化系统资源的配置。此外,本文在构建支付方式中的激励因素作用机制模型基础上,提出支付方式必须与其他规制、管理手段相互协同和促进,应当建立管理信息系统、制定诊疗规范及制度、制定监测评价系统并加强供方内部管理。
6.运用结果链逻辑框架对购买策略改革干预的监测评价：所设计的购买策略已在宁夏自治区两个试点县启动实施,第一阶段聚焦于福利包的调整和支付制度的改革。虽然项目还在试点初期,尚缺乏有关干预措施效果及影响的明确证据,但基于实证,各项试点工作在稳步推进中,各方反应基本良好,预期行为改变发生。基层门诊服务利用大幅上升,两试点县基层医疗机构2010年新农合门诊量分别是2009年同期2.5倍和4.0倍,且试点县乡、村两级人均就诊次数增加量分别高于对照县；资源利用效率有所提升,两试点县新农合住院率下降,新农合门诊就诊率则分别从年人均0.99次和0.41次上升至2.61次和1.43次,试点县内由新农合支付的乡村两级门诊服务中,超过或接近一半发生在村一级,基本医疗服务下沉效果显著,乡村两级机构次均门诊费用呈下降趋势,且实施支付制度干预的乡镇卫生院次均门诊费用较对照乡镇卫生院下降得多；项目进展总体趋向与设计相符。
政策建议
1.在农村地区进行卫生服务公共资金投入时,以系统整体绩效改善为目标,逐步引入“战略性购买”的理念和策略。即将卫生服务的购买功能与提供功能适度分离,实施以公众需要为基础、成本效益理念、竞争理念、契约理念、绩效评估为核心的目标型管理,科学发展“购买什么、怎么购买、向谁购买”的购买核心策略以及作用于组织、制度,确保核心策略顺利实施的购买支持保障策略。
2.重视居民预防保健和常见病、多发病及慢性病诊治的需要,基于此类服务的成本效果特点,调整农村的医疗卫生福利包,即购买保障的范围和水平,从以前关注重大疾病／住院服务向公共卫生和基本医疗服务进行战略性调整,提高新农合门诊服务,尤其是基层机构报销比,用经济激励机制调控需方的需求和服务利用行为。
3.整合公共卫生和基本医疗服务筹资。现阶段可将政府下拨的公共卫生经费与新农合补助及居民缴付的参合资金进行整合,从中划拨出基本医疗卫生服务经费,并在对供方进行支付时,与公共卫生服务和基本医疗服务的整体绩效挂钩,以此实现资金整合的效果,提高购买方对供方的调控力,加强资金的使用效率。
4.为平衡卫生服务可及性、公平性、效率、质量等目标,建议采用复合型支付方式。对基本医疗卫生服务,改革原有单纯按项目付费机制,采用按人头付费、按项目付费、按绩效支付的协同方式,以促使供方在服务量、效率和质量方面的同步提升。
5.建议通过适当的薪酬、合理的职能定位、诊疗规范以及强化培训,引导并保障供方人员的保留和生产力的提高,向卫生专业人员提供适当的激励以解决西部农村村级卫生人员不足、生产力低下的问题。
6.通过经济激励机制的设计,给予乡镇卫生院对村卫生室收入的考核分配权和结余留用权,强调卫生院对村卫生室绩效的连带责任,并与卫生院的绩效收入挂钩,以调动乡镇卫生院的积极性,落实乡镇卫生院对村卫生室的管理,推进“乡村一体化”,从而优化乡村资源配置,规范服务行为,提高村医服务能力,实现卫生服务的下沉以及效率的提升。
7.在基本医疗卫生服务购买过程中,建立需方参与机制。可以通过建立居民管理小组、监管理事会等形式,充分发挥居民在购买决策、绩效考核、监督管理等方面的话语权,强化购买方对需方的代表性。同时加强对居民的健康教育,帮助居民正确表达其健康需要。
8.中央和上级政府对地方政府及购买机构下放购买决策权和行动权,以增强购买方对需方的反应性。地方政府及购买机构必须加强自身对卫生服务购买的进一步理解、信息收集和分析、与供方谈判协商、对供方绩效监测评价等能力以及公信力的建设。
9.基本医疗卫生服务的提供与保障,必须坚持政府主导与市场机制相结合的原则,强调政府在服务购买中的监管。中央政府和省级政府以战略性购买政策方向和法规框架的确立,信息收集和利用,各方利益的平衡为主要干预与规制范畴,需要特别加强对地方购买机构的监督和考核；同时作为公立机构所有者,在目前阶段还要通过“补供方”形式加强对基层医疗卫生机构基础设施和人力资源的投入,加强供方的能力建设。
10.战略性服务购买的每个环节都离不开对供方日常卫生服务信息的收集和处理,信息的需求量以及处理方式已完全不同于传统的被动性购买方式下对信息的要求,因此必须加强管理信息系统的投入和建设。此外,还必须通过明确供方定位、制定诊疗规范、提高供方能力和自主性、加强供方的职业道德教育、对患者实施健康教育等一系列作用于供需双方的管理和规范等支持保障策略,来促成购买核心策略的实施,并放大服务购买的效应。
11.对本研究所涉及的相关购买策略进行严格而全面的监测和评估,其他卫生服务购买干预项目亦如此。
研究总结
本文引入卫生服务战略性购买理念,在对购买相关理论实践总结基础上,与卫生系统模型结合提出战略性购买策略的研制思路,并通过案例在现实中对理论进行应用,从服务购买角度对宁夏地区基本医疗卫生系统问题进行分析,之后对具体的购买策略进行改进设计,并在实践中进行验证。本研究中所呈现出的基本医疗卫生服务购买理念和策略研制思路、所设计的购买策略及支付方式改革策略具有可扩展性和可借鉴性,对其他地区尤其是西部农村地区具有示范意义。
Background
"Equitable and universal access to basic health care for all" is established as the strategic goal of the new health reform plan in China. The Basic health care sector, comprising public health care and basic medical care, is regarded as the foundation as well as the core of the whole health system. The equity, efficiency and quality of the basic health care sector is closely linked to the population's health and welfare, and also count for the optimization of the performance of the health system.
Rural health is the key of the health system in China. However, the basic health care and its delivery system, the township health center and village clinics, in rural area suffered inadequate funding for a long time. More seriously, the invested funds were not effectively and efficiently used. Market failure and government failure prevailed in the health sector, while the irrational use of health resources, the unreasonable health demands as well as the perverse incentives made things worse that resulted in inefficiency, low quality of basic health care and waste of resources. Therefore, the effective strategies to promote the access and to enhance equity, efficiency and quality of the basic health care must be sought along with the fund increases to drive the health system change well and improve the health outcomes of the rural population.
In China, the primary health facilities and its provided services are funded through two main channels:government fund and health insurance fund. Generally, the public fund goes in two ways:one is direct subsidies or budgets to the public facilities, the other is an independent purchasing role buy the health services for all or specific population. Recently, there is a common trend in health sector reform worldwide, which is a move from hierarchical and integrated forms of service delivery and finance towards devolved models based upon the separation of the responsibility for purchasing services from the responsibility for providing them. However, the passive exercise of purchasing that involves mere post-reimbursement of expenses to providers is far from enough. Hence, the strategic purchasing based on purchaser-provider split is promoted as a key policy instrument to improve health system performance and becomes a heated topic for research and practice around the world.
The priority of health care reform agenda is "to ensure basic health care, to strengthen primary health facilities and to establish mechanisms to achieve the goal", with the idea of purchaser-provider split and strategic purchasing written in the reform plan. However, the practice of purchasing of basic health care, particularly in rural areas, is in its very first stage while the study on purchasing is still in the initial process of introduction of concepts. There are limited researches on the status quo of purchasing system, design of purchasing strategies, say nothing of the evaluation of purchasing interventions in China. Thus in the context of the new health care reform, it is essential to conduct studies on purchasing system of basic health care, especially in rural areas, to develop the purchasing strategies on what to buy, how to pay and from whom to buy to achieve rational use of resources and effective motivation for providers in the condition of limited competition and low capability of providers, making the full use of the government fund and the medical insurance fund to fulfill the ultimate goal of health system.
Objectives
Using normative study to understand the relationships between different actors in health care purchasing system and the interactive mechanisms among the relationships, based on which the approach framework to design and develop purchasing strategies is established. Applying theories into practice through case study:to diagnose the main problems of basic health care system performance in rural areas and find the root courses from the perspective of purchasing, to design series of purchasing strategies, especially the payment methods and then monitor and evaluate the purchasing interventions after implementation.
Methods
Employ three theoretical frameworks. The policy cycle framework was adopted as the general approach of the research, starting from the problem definition, through diagnosing, design, political decision, implementation and ending with evaluation; the development and reform framework was used as the method to find the causes of the problems and to develop the design approach framework of the purchasing strategies; the result chain framework was taken to guide the monitoring and evaluation of the purchasing interventions.
Case study was conducted to make application of theories and rationales. Rural area in the Ningxia Hui Autonomous Region was selected as a case for its representativeness and reform foundation in advance. Two counties in Ningxia (Haiyuan and Yanchi) were investigated in detail, and then the design, monitoring and evaluation of the strategic purchasing policies are developed accordingly.
Some investigation methods were used. Literature review was applied to realize the rationales and practices of health care purchasing home and abroad and the secondhand data of system performance before and after intervention; household survey and facility survey were conducted in February 2009 to attain the information about health care demand and utilization of the population as well as situations of the primary facilities, health workers and health care operations; qualitative interviews were intended to know about problems and reasons, stakeholders'appeals and their views and appraisals after interventions implementation.
Furthermore, PETS analysis and difference-in difference method were driven to verify feasibility and evaluate the effect and impact of the interventions respectively.
Results
1. Summary of rationales and practices of strategic purchasing:Aimed at improving the health system performance, strategic purchasing involved the realization of public's health need, emphasis on cost-effective services, reconstruction of incentives for providers, encouragement in competition and requirement of government stewardship. Proactive decisions were made about which health care services should be purchased, how and from whom. There were at least four roles and three principal-agent relationships inside the purchasing systems:the purchaser acted as the consumers'agent in the purchase of health care services on their behalf; the purchaser employed a providers to deliver the appropriate mix of health care, of acceptable quality, at an agreed price; the purchaser acted as agent for the government or state to rationally allocate health resources. In order to make the agent acts well, series of tools and mechanisms must be adopted to ensure the relationships.
2. Combining the purchasing theories with the health system model to produce the approach framework for developing heath care purchasing strategies:Purchasing strategies comprised the "core policies" deciding which interventions should be purchased, how they should be purchased and from whom from the purchaser's standpoint as well as the "supporting and ensuring policies" mainly aiming at the organization and institution environment from the perspective of the health system. According to the health development and reform framework, instruments towards the financing, payment and part of the organization knobs could be used to establish the core policies of purchasing primarily acting on the relationship between purchaser and provider; other organizational, regulation and behavioral instruments were proposed to work as the supporting and ensuring policies.
3. Applying theories on empirical case to define and diagnose basic health care problems in rural area:public health care and basic medical care are the key points for rural population's health need, however empirical data showed that the accessibility, efficiency and quality of basic health care were low while the primary health facilities, particularly the village clinics were incapable and short of supply. Purchaser-provider split already existed in the system; however, the purchasing was in a passive form. The main reasons for the problems were the inappropriate mix of core purchasing policies, and the root courses were based on the purchaser's insufficient representativeness for the population, poor mechanisms for the purchaser to control providers and limited stewardship of the government.
4. According to the approach framework for developing heath care purchasing strategies to design the improved purchasing strategies for the rural area:core policies implemented by the purchasers (the local government, the health department and the NCMS office) including financial strategies to integrate public health care fund with NCMS fund, adjust the scope and reimbursement rate of benefit package; payment strategies to change the payment method, enhance provider's income and pay for performance; organizational strategies which were derived from the payment strategies to integrate the township and village delivery system and to introduce competition. Besides, defining the roles of the township and village providers, establishing mechanisms for the residents to participate and monitor the purchasing processes, launching health education as well as training to promote the specialty and management competence of providers were projected to act as the supporting and ensuring policies.
5. Developing the payment methods as core mechanism in details:blended payment methods acted on the entire township (including the township health center and all the village clinics) were taken to trade off the multiple objectives of the basic health care, prepaid capitation of the public health care and basic outpatient care targeting efficiency, fee-for-service of medical fee per visit enhancing accessibility, and pay-for-performance of the reserved 30% budget improving service quality. Based on the design, integration of township health center and village clinics and competition may emerge in the context of changed incentives, further optimize the resource allocation. A model of the mechanism of action of the financial incentives among the payment methods was produced and accordingly, financial incentives have to be cooperated and promoted mutually with other regulation and management tools. So MIS, protocols, monitoring and quality assurance system and the internal management of providers must be well developed.
6. Monitoring and evaluating the purchasing interventions with the guide of results chain:the designed strategies have been implemented in the two pilot counties, mainly focused on the adjustment of benefit package and reform of payment system in the first phase. Though the pilot was still in its initial stage and there was lack of clear and definite evidences of the effects and impacts, some positive phenomenon were witnessed:intended behavioral changes of providers and demanders appeared, utilization of outpatient services in primary facilities increased rapidly and dramatically, efficiency of resource use was seen improved. Thus the progress of the project was in line.
Suggestions
1. To introduce "strategic purchasing" when public fund is invested into the health care in rural areas to improve the system performance.
2. To adjust the benefit package to fulfill populations'needs for preventive health care and medical care of common diseases and chronic diseases.
3. To integrate the public health care fund and basic medical care fund (usually NCMS fund) sources together to enhance purchaser's power over providers.
4. To adopt blended payment methods to balance the multiple goals of health care to achieve accessibility, equity, efficiency and quality. Change the payment to primary health facilities for basic health care form pure fee-for-service method to combined capitation, fee-for-service and pay-for-performance.
5. To offer proper level of income, rational definition of the provider role, reasonable norms and protocols and intense trainings to providers to solve the problem of insufficient human resources and low productivity.
6. To make use of financial incentive structures to promote the integration of township and village providers, for example, the township health center is permitted to share the village clinic's residual or takes responsibility of the performance of the latter which is also related to its own revenue.
7. To establish the population participation mechanism such as citizens'juries or purchasing boards to improve the agency function of the purchaser.
8. To devolve the right of decision making and action towards lower-level, such as local government and local medical insurance organization, while the purchasers strengthen their capacity and credibility to reinforce the reactiveness of purchasing.
9. To persist in government's domination in the purchasing through stewardship and scrutiny and preserve government funding in the infrastructures and human resources of the public providers.
10. To lay great efforts on construction of management information system to support the process of purchasing and to integrate other management and regulations such as provider positioning, clinical guidelines constitution, increasing provider capability and autonomy, provider ethics training and demander health education, with the core purchasing strategies.
11. To carry out rigorous and comprehensive monitoring and evaluation of the designed interventions involved in this research and so is for other purchasing programs.
Summary
This study introduced the concept of strategic purchasing of health care for the first time. Based on the summary of purchasing theories and the model of health system, an approach framework for designing and developing purchasing strategies was established. Then theories and the conceptual framework were put into practice through a case study. The problems of the health system in Ningxia rural area was defined and diagnosed form the purchasing perspective, the concrete purchasing strategies and policies were then developed and the results were validated in the real world. The idea of strategic purchasing, the approach to produce purchasing strategies and the specific purchasing strategies and payment methods developed in this study can be learned, extended and generalized, as a demonstration for other places, the western rural areas in particular.
引文
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