卫生资源合理配置研究
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摘要
基于世界卫生组织等的研究与各国实践经验，对公共卫生的投入是改善人群健康性价比高、物有所值的领域。本论文选取公共卫生领域的资源配置作为研究对象，采用优先级配置（priority setting）为研究视角，除了其本身是国际卫生资源配置的研究趋势，也是基于卫生资源作为稀缺资源这一普世前提所引发的中国思考。借助卫生资源的优先级配置改善中国卫生资源配置公平性，需要遵循适切的优先标准和公平程序，提高政府资源治理能力。
本研究首先在对比评析国外政府应对稀缺资源供需矛盾的施政措施的基础上，检视优先抉择这一不可避免的问题。同时在学术领域，多元哲学流派对合理配置、公平分配乃至优先配置问题都有其思辨，而这些哲学思想如何影响优先分配抉择又与一国的社会背景密切相关。对我国来说，确立围绕以公平为目标的卫生资源优先级配置，并非狭隘地排斥效率等其他配置元素，而是以动态而辩证的观念看待效率与公平的平衡促进关系。
其次，探讨卫生资源优先级配置程序公平的实现问题，采用国内外对比研究和案例分析的方法，运用合理问责框架（A4R）、公众参与研究（PAR）对资源配置的两种程序进行评价，建议加强卫生决策过程的透明公开，实现各利益方的参与赋权，提高政府决策能力并落实政治承诺。
再次，分析卫生资源优先级配置的实质公平实现问题，主要采用政策分析和案例分析方法。一是将善治作为治理的理想状态，分析我国卫生资源配置的历史变迁摸清治理的实然状态，并借助多元治理手段提出改善建议；二是以老年人群、贫困人群等重点优先人群为例，提出对应的治理措施；三是制定我国卫生资源优先标准和项目。通过pubmed、CNKI等数据库以及国外相关机构网站，评估国外优先级配置的价值观念、伦理原则和优先标准，为我国相关优先分配抉择提供对比参考。
最后是实证研究。一是采用公平性基准方法（BF）对全国卫生资源数据展开分析，研究结果说明，卫生资源配置政策应继续围绕减少城乡二元化，缩小地域差距而展开，并特别加强对西部地区的扶持。二是开展重庆市卫生局行政人员的优先级配置态度调查，设计Likert态度量表获取量化数据。调查摸清了重庆市级卫生行政机关人员偏好，即最愿意优先资源投入的第一方阵以及最重要的优先决策标准，调查对象的态度基本能保障卫生资源优先级配置的顺利实施。
本研究基本理清我国卫生资源优先级配置的优先项目和优先决策标准，首次将合理问责框架、公平基准等分析方法运用于中国情境并提出相应政策建议；初步探明卫生资源优先级配置的省级卫生厅行政人员认知态度，将为我国开展卫生资源优先级配置提供理论和实证参考依据。
The evidences from researches conducted by WHO, demonstrate that investment inpublic health is cost-effective and efficient for improving population health. However,limited health resource and unlimited demands obsessed health policy making andmanagement of China all the time. Currently, priority setting is a well acknowledgedmeasure for health resource allocation around the world, which provides a perspective toconsider the universal premise of scarce health resource in China. Thus, this study focuseson the allocation of health resource by setting priority for health investment, is an attemptto advance the fairness of Chinese health resource allocation through the way of bettergovernance, explicit priority criteria and more procedural fairness.
To attain the aim of this study, this study first reviews the measures for dissolving thedilemma of supply and demand on health resource employed by foreign countries. Thefindings show that priority setting is an effective strategy that commonly used, although thestrategy is specific for the context of each country. Moreover, those strategies areinfluenced by the diverse philosophical theories, which provide a source of reference onrational allocation, equitable distribution and allocation priority. Based on the researchfindings, this study believe the fairness should be the basic principle of the priority settingin China. Such belief provides a dynamic and dialectical view on the balance and promotionof efficiency and fairness, rather than excluding other allocation factors, such as efficiency.
Next, this study explores the procedural fairness on health resources priority setting byusing comparative cases study. Accountability for Reasonableness (A4R) and ParticipatoryAction Research (PAR) are used to evaluate the resource allocation procedure. The resultsillustrate the following measures should be carried out in order to perform the proceduralfairness: to set up a transparent and open health decision-making process; to empowerrelative stakeholders; to advance government decision-making capability; and to meet the political commitment of government.
Then, this study discusses how to implement the priority setting on the health resourceallocation for carrying out fairness in three steps. Firstly, this study finds that the idealmodel of governance is stewardship by analyzing relative policy and cases. To attain thisideal state, promoting recommendations should comprehensively understand the historicalchange of health resource allocation governance and adopt diverse governance means.Secondly, relative measures emphasized on the elderly, the poor and other priority groupsare put forward. Thirdly, this study summarizes performance criteria such as values, ethicalprinciples etc. on setting priority of health resource allocation by reviewing relativeliterature from Pubmed and CNKI, to put forward china’s own prioritize criteria andpriority area.
Finally, this study conducted two empirical studies in order to implement the prioritysetting of health resource allocation. One study analyses the relative data of health resourceof the whole country by using the Benchmark of Fairness (BF). The results demonstrate thatthe allocation policy on health resource should emphasize on: to fill the gap between urbanand rural areas; to shorten regional disparities; to strengthen the support for Western regionof China. The second study carries out a survey on the administrators’ attitudes towardpriority setting in Chongqing Municipal Health Bureau used three Likert scales. The resultsshow the preference of Chongqing Municipal Health Administrative agencies, their willingto prioritize the health resource and the foremost priority decision criteria. It finds that theytend to support the implementation of setting priority on the health resource allocation.
本研究首先在对比评析国外政府应对稀缺资源供需矛盾的施政措施的基础上，检视优先抉择这一不可避免的问题。同时在学术领域，多元哲学流派对合理配置、公平分配乃至优先配置问题都有其思辨，而这些哲学思想如何影响优先分配抉择又与一国的社会背景密切相关。对我国来说，确立围绕以公平为目标的卫生资源优先级配置，并非狭隘地排斥效率等其他配置元素，而是以动态而辩证的观念看待效率与公平的平衡促进关系。
其次，探讨卫生资源优先级配置程序公平的实现问题，采用国内外对比研究和案例分析的方法，运用合理问责框架（A4R）、公众参与研究（PAR）对资源配置的两种程序进行评价，建议加强卫生决策过程的透明公开，实现各利益方的参与赋权，提高政府决策能力并落实政治承诺。
再次，分析卫生资源优先级配置的实质公平实现问题，主要采用政策分析和案例分析方法。一是将善治作为治理的理想状态，分析我国卫生资源配置的历史变迁摸清治理的实然状态，并借助多元治理手段提出改善建议；二是以老年人群、贫困人群等重点优先人群为例，提出对应的治理措施；三是制定我国卫生资源优先标准和项目。通过pubmed、CNKI等数据库以及国外相关机构网站，评估国外优先级配置的价值观念、伦理原则和优先标准，为我国相关优先分配抉择提供对比参考。
最后是实证研究。一是采用公平性基准方法（BF）对全国卫生资源数据展开分析，研究结果说明，卫生资源配置政策应继续围绕减少城乡二元化，缩小地域差距而展开，并特别加强对西部地区的扶持。二是开展重庆市卫生局行政人员的优先级配置态度调查，设计Likert态度量表获取量化数据。调查摸清了重庆市级卫生行政机关人员偏好，即最愿意优先资源投入的第一方阵以及最重要的优先决策标准，调查对象的态度基本能保障卫生资源优先级配置的顺利实施。
本研究基本理清我国卫生资源优先级配置的优先项目和优先决策标准，首次将合理问责框架、公平基准等分析方法运用于中国情境并提出相应政策建议；初步探明卫生资源优先级配置的省级卫生厅行政人员认知态度，将为我国开展卫生资源优先级配置提供理论和实证参考依据。
The evidences from researches conducted by WHO, demonstrate that investment inpublic health is cost-effective and efficient for improving population health. However,limited health resource and unlimited demands obsessed health policy making andmanagement of China all the time. Currently, priority setting is a well acknowledgedmeasure for health resource allocation around the world, which provides a perspective toconsider the universal premise of scarce health resource in China. Thus, this study focuseson the allocation of health resource by setting priority for health investment, is an attemptto advance the fairness of Chinese health resource allocation through the way of bettergovernance, explicit priority criteria and more procedural fairness.
To attain the aim of this study, this study first reviews the measures for dissolving thedilemma of supply and demand on health resource employed by foreign countries. Thefindings show that priority setting is an effective strategy that commonly used, although thestrategy is specific for the context of each country. Moreover, those strategies areinfluenced by the diverse philosophical theories, which provide a source of reference onrational allocation, equitable distribution and allocation priority. Based on the researchfindings, this study believe the fairness should be the basic principle of the priority settingin China. Such belief provides a dynamic and dialectical view on the balance and promotionof efficiency and fairness, rather than excluding other allocation factors, such as efficiency.
Next, this study explores the procedural fairness on health resources priority setting byusing comparative cases study. Accountability for Reasonableness (A4R) and ParticipatoryAction Research (PAR) are used to evaluate the resource allocation procedure. The resultsillustrate the following measures should be carried out in order to perform the proceduralfairness: to set up a transparent and open health decision-making process; to empowerrelative stakeholders; to advance government decision-making capability; and to meet the political commitment of government.
Then, this study discusses how to implement the priority setting on the health resourceallocation for carrying out fairness in three steps. Firstly, this study finds that the idealmodel of governance is stewardship by analyzing relative policy and cases. To attain thisideal state, promoting recommendations should comprehensively understand the historicalchange of health resource allocation governance and adopt diverse governance means.Secondly, relative measures emphasized on the elderly, the poor and other priority groupsare put forward. Thirdly, this study summarizes performance criteria such as values, ethicalprinciples etc. on setting priority of health resource allocation by reviewing relativeliterature from Pubmed and CNKI, to put forward china’s own prioritize criteria andpriority area.
Finally, this study conducted two empirical studies in order to implement the prioritysetting of health resource allocation. One study analyses the relative data of health resourceof the whole country by using the Benchmark of Fairness (BF). The results demonstrate thatthe allocation policy on health resource should emphasize on: to fill the gap between urbanand rural areas; to shorten regional disparities; to strengthen the support for Western regionof China. The second study carries out a survey on the administrators’ attitudes towardpriority setting in Chongqing Municipal Health Bureau used three Likert scales. The resultsshow the preference of Chongqing Municipal Health Administrative agencies, their willingto prioritize the health resource and the foremost priority decision criteria. It finds that theytend to support the implementation of setting priority on the health resource allocation.
引文
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