With the development of the economy and the continuous improvement of the people's living standards, people are paying more attention to the quality of life and health, and consequently to the performance of the health system. However, how to further improve the performance of the health service system to meet the increasing health service needs of the general public has become a subject of widespread concern. International organizations and scholars from various countries are actively exploring and researching. Among them, the representative studies include: WHO's World Health Report 2000 on health service system performance assessment methods (1) and the World Bank's "Flagship Course on Financing for Health Reform and Sustainability" on health service system diagnostic theories and methods (2). In this paper, we will take the health service system performance assessment framework proposed by WHO as the goal, and the health service system diagnostic tool proposed by the World Bank as the analytical tool, and systematically analyze the results, causes, and ways and means of improvement that lead to the current stage of the poor performance of the health system in China.
1 Health Service System Performance Objectives
The health service system is a complex system, and any individual, group, organization, and related resources whose main purpose is to improve health status belong to the scope of the health system. Its components include: preventive health care and medical service providers; financing intermediary organizations; producers of inputs such as medicines, reagents, medical equipment, and doctors and nurses; and health service planners and administrators. As can be seen, the health service system is characterized by multiple participants. In this system, they are interconnected and interact with each other, yet they are constrained by each other and need to work *** together to achieve the ultimate goal of the system. For this reason, the subsystems can only ensure the efficient realization of the ultimate goal of the health service system if they work in an orderly and coordinated manner with each other in accordance with the requirements of the ultimate goal of the system. However, the fact that different participants have different subgoals, some of which may even deviate from the health system's ultimate goal, makes it difficult to realize the health service system's ultimate goal. For example, the objective of a hospital, which is the window unit of the health system, is clearly aligned with the ultimate goal of the health service system to improve the health of the population. It has to embody the purpose of saving lives and serving people. And it has to have the active support and cooperation of the subsystems. To do: to money money, to things, to medicines, otherwise, the hospital to achieve its goals will inevitably have to be discounted. And as a business producers of various medical consumables and equipment, although its products can be used to improve health activities, but according to the theory of market economy, its purpose is mainly to maximize the pursuit of economic returns. Obviously, the objectives of hospitals are inconsistent with those of enterprises. Due to the complexity of the health service system itself and its multi-party participatory nature, a variety of ways and means are needed to enable it to achieve its set objectives. On the premise of clarifying its performance objectives, various institutional and institutional measures are utilized to ensure that the various sub-systems are coordinated to serve the ultimate goal of the health service system. To this end, the objectives of the health service system must first be further clarified, as pointed out by WHO in its World Health Report 2000: although health promotion is a major objective of the health system, it is not the only one. The goal of good health has two meanings in its essence: good quality and minimization of disparities between individuals. Quality means that a health system responds appropriately to the legitimate expectations of the population at large; minimizing disparities means equity. The World Health Report 2002 proposed, for the first time in the world, that health system performance goals should include three dimensions: improvement in health status, responsiveness to the general and reasonable expectations of the population, and fairness of financial contribution. contribution.) Responsiveness is a new concept that includes two aspects: respect for people and client-centeredness. "Respect for the human being" means that clients are treated with respect when they seek medical care; health care workers are courteous and polite; patients' privacy is protected during examinations and treatments; patients have autonomy, participate in decisions about treatment plans, and have the right to make decisions; patients have the right to privacy, and health care organizations are able to maintain the confidentiality of medical histories and reports; and health care workers are able to listen carefully to clients and their families and to make decisions. are able to listen carefully to clients and their families and have good communication with them. The "client-centeredness" includes four aspects: the health care organization is able to pay attention to the needs of the clients in a timely manner, and can quickly access health care services when needed; the infrastructure is of good quality, with enough space, seating, and fresh air in the waiting room, and the facilities are clean and provide healthy and tasty food for the patients; the clients have the right to free choice, and can freely choose their medical history and medical reports; the health workers are able to listen carefully to the clients and their families, and have good communication with them. freedom of choice, able to freely choose various health care institutions and health care personnel; health institutions have good social support functions, allowing service users' relatives and friends to visit them, and being able to freely participate in various social activities during hospitalization. Among them, the health status and responsiveness indicators are subdivided into 2 aspects: level and distribution. That is, they are portrayed from 2 perspectives: average status and distribution. With this goal in mind, WHO evaluated the performance of health services in 191 member countries. The country with the best horizontal health status is Japan, followed by Australia, and in third place is France. Their healthy life expectancy (DALE) is 74.5, 73.2 and 73.1 years respectively. The top 3 countries in terms of health distribution are Chile, UK and Japan. The country with the best level of responsiveness is the United States, followed by Switzerland and Luxembourg. The United Arab Emirates and Bulgaria are the top 2 countries in the distribution of responsiveness, followed by 36 countries in third place. Colombia and Luxembourg ranked first and second, respectively, in terms of equity of financing. Combining these 3 dimensions, the top 3 countries in terms of overall health system performance are Japan, Switzerland and Norway. Our country ranked 81st in horizontal health and 101st in health distribution; we tied with Turkmenistan for 88th in horizontal responsiveness and Guyana for 105th in responsiveness distribution; and we ranked 188th in financing equity, the fourth lowest. Overall performance is listed 144th. It is evident that the performance of our health system is not satisfactory. Why did we get such results? By applying the World Bank's "Flagship Program on Health Reform and Sustainable Financing" health system diagnostic tool, we can systematically analyze the results.
2 Analysis of the performance of the health service system in China
Key factors affecting the performance of the health service system
The World Bank experts believe that the diagnosis of the performance of the health system should be considered in terms of five key control points. They are the organization of the health system, health financing, payment methods of service providers, regulation, and social marketing. They will have an impact on health system performance.
First, look at the macro-organization of the health system in our country and the relationship between the subsystems. When talking about the health system in China, people tend to refer only to the narrow concept of the units and individuals who directly provide various medical and health services, such as various types of hospitals, community health service centers, disease control centers, and so on, while ignoring the impact of the production of health-related units, like medical equipment, medical consumables, etc., on the intermediate performance of the health system as a whole. In fact, after the reform and opening up, it was not the cost of medical labor that first drove up the cost of medical services in China, but rather the rise in the prices of water, electricity, gas, and a variety of commodities related to medical services. Even now, they continue to drive up the cost of medical care (of course, the realization of such cost increases requires the cooperation of other conditions, such as financing, payment and control measures, etc., which we will discuss below). These production units are economic entities that seek to maximize revenue. In a market economy, their behavior is undoubtedly correct. However, the rising cost of healthcare has forced healthcare services to require more compensation, otherwise, it would be difficult to realize its social purpose of serving the people. And there are 3 basic channels for the compensation of medical services: government, society and individuals. The government's input comes from the treasury, and the society's input comes mainly from social medical insurance. If compensation for rising medical costs cannot be obtained from these two sources, then it can only be obtained from consumers. And this is bound to undermine the ultimate performance of the health system - the equity, health, and even responsiveness of financing. For such financing will surely incentivize providers to focus more on the responsiveness of consumers with the ability to pay than on the responsiveness of those who do not have the ability to pay. Because the country still lacks an integrated management authority capable of coordinating the interests of the various subsystems involved, virtually all of them have been working for their own goals for nearly two decades, ignoring the performance goals that the health system ultimately seeks to achieve. Even from the narrow definition of the health system, the organization of the health system in China is fragmented, the allocation of resources is obviously disordered, the allocation of inefficiency, there is still no authoritative management department to coordinate the interests of all parties, the implementation of the responsibilities, rights and benefits of the management of the unity of the work. 2003 April-May outbreak of the SARS epidemic reveals the shortcomings of this.
Look at our health financing model. In order to allow hospitals to solve their own compensation problems, since the 1980s, China decided to implement reforms to the original low-cost charging policy, the hospitals to adopt new technologies, new projects to take higher-than-cost pricing (the drug wholesale price differential of 15% of the hospitals are still available to the policy of concessions) to cross-compensate for those below-cost price of medical services. This is because, in order to survive and develop, hospitals must also rely on this new policy. Otherwise, it will be difficult for hospitals to survive and develop. The service objectives of hospitals are complicated by the addition of the objective of pursuing financial gains to sustain development to the objective of saving lives and serving the people. It is worth noting, however, that this new financing policy is aimed at the service utilizers. It trades the survival and development of the health system for the loss of equity in financing. This is because 80 per cent of the country's farmers are not yet covered by any form of health insurance and must pay out-of-pocket for their care. This type of financing is bound to increase their financial burden, and it is easy to understand why the equity of health financing in our country ranks fourth from the bottom among the 191 member states.
From the point of view of the supply-side payment method, the vast majority of hospitals in China have been following the oldest payment method for health services, which is the payment by service item. The so-called payment by service program is for different medical services, through a certain method to calculate its price, according to this price payment method of medical services. According to this payment method will inevitably lead to the more services provided, the higher the price of each item, the higher the cost paid to the hospital. China's current financing policy and payment system determines the health service provider's income has a close relationship with the services it provides, the medical supply side of the sale of drugs and the provision of high-precision equipment inspection program has a strong economic incentive, coupled with asymmetric information on medical services, the service provider will inevitably provide excessive high-cost medical services.
Let's analyze the regulatory aspect again. Regulation is the use of coercive power by the state to change the behavior of the population, which includes legal provisions and mandatory documents issued by all levels of government to individuals and organizations. Its instruments include constitutions, laws, proclamations, orders, regulations, and administrative rules and regulations issued by governmental and non-governmental organizations. Regulation in the health care market is aimed at buyers and sellers of health care. Regulation is the main tool of the government to ameliorate market imperfections. Its purpose is to create a favorable environment for the functioning of the health care market and to correct market failures. To this end, we need to clarify all kinds of property rights in the health field, prevent all kinds of fraud, and ensure the fulfillment of all kinds of contracts. At the same time, we must ensure the quality of health care services, for example, by setting up an access system for health manpower, medicines and medical equipment. In the face of pressure on the affordability of health services, to ensure that scarce health resources are utilized in areas that can bring about the best health outcomes, technical assessments of priority health interventions are mandatory, and so on. However, China is currently lagging significantly behind in the regulation of health, with weak control of health manpower, capital investment, etc., and a relatively inefficient allocation of people, money, and materials.
3 Analysis of the performance of China's health service system
Individual behavior is influencing the performance and health status of the health system in many ways and in many ways. Changing individual behavior through social marketing in a direction that is conducive to improving health system performance is the fifth key control factor that affects health system performance. This is an area in which we have done well in the past and for some time had been recognized internationally by consensus. However, in recent times, we have neglected its importance. "SARS has once again served as a wake-up call that each person's hygiene practices are not only relevant to him or her as an individual, but also affect the health status of the population as a whole.
In summary, it can be seen that our decentralized health system organization model that lacks comprehensive goal guidance, inappropriate financing mechanisms and payment methods, and inadequate control measures are the reasons for the low performance of the health system. Therefore, in order to improve the performance of the health system, we must address the root causes of the problem and implement reforms to the existing imperfect health system.
3 Countermeasures to improve the performance of China's health service system
3.1 Macro reform of the organization of the health system According to the characteristics of the health system, the establishment of the "Ministry of Health" or the "Ministry of Health and Welfare", which has the function of integrating and coordinating the management of all health-related sectors, The Ministry of Health and Welfare was established in accordance with the characteristics of the health system, with the function of comprehensively coordinating and managing the affairs of all health-related sectors. As can be seen from the preceding analysis, the lack of an integrated management department to coordinate the interests of all parties will inevitably reduce the performance of the health system as a whole. China's experience in health reform over the past period of time has also proved that health reform requires the participation and cooperation of multiple sectors. At present, the functions of the State Ministry of Health are too narrow, which is not conducive to the optimization of resource allocation for the entire health system. We should not only integrate the National Family Planning Board and the Chinese Medicine Bureau into the Ministry of Health, but also bring medical insurance and population welfare under the jurisdiction of the Ministry of Health and Welfare, and even include the management of drugs and food safety in its scope of functions. Looking at the macro-organization of health systems in various countries around the world, no matter whether it is the United Kingdom, where the government is the mainstay, Australia and Canada, where social insurance is the mainstay, or the United States, where marketization is the mainstay, the functions of their ministries of health are broader than those of our current national ministries of health. This is conducive to the health-related sub-systems to give full play to their respective roles under the guidance of the overall objectives of the health system, to improve the efficiency of the allocation of health resources in the whole society, and to safeguard the social equity as well as the sustainable development of the health system.
3.2 Reform of the health financing mechanism and payment method China's current financing mechanism and payment method, although it has played a positive role in alleviating the shortage of funds for the health system for a period of time in the past, its shortcomings have been exposed more and more clearly. It undermines the equity of health financing, which in turn ignores to a certain extent the responsiveness of disadvantaged people to the health system, making our country rank 105th to 106th in the distribution of responsiveness. In order to reverse the current inappropriate financing mechanism, firstly, government health investment should be increased; secondly, the price of health services should be adjusted on the basis of cost, so that the relationship between the cost and the price of all health services is consistent, which can reasonably reflect the labor value of health services without excess profits, and ultimately eliminating the phenomenon of cross-compensating the cost of medical services with the income from new and high technology equipment above the pricing. Implement the separation of medicine and cut off the financing mechanism that supports doctors with medicine. In the cities, expand the coverage of social medical insurance; in the countryside, consolidate and develop various forms of rural medical security systems. Reform the payment method of all medical insurance systems, from postpaid to prepaid, to increase the cost consciousness of service providers and users.
3.3 Strengthen the control of the health system and create a favorable environment for the operation of the health care market Due to the lack of information for consumers to correctly evaluate the quality of health care services in the health care market, and the fact that health care service providers act as consumer agents, there is a "moral damage" and "cream-skimming" in the health insurance. The "cream-skimming" phenomenon in health insurance makes it necessary to regulate the health care market. Take measures to limit the occurrence of supply-side induced demand for services, limit the provision of services by unqualified service providers, establish standards for the accreditation of health care organizations, control the price of services and insurance rates, and adhere to the anti-monopoly, encourage competition and other measures to improve the operation of the health care market mechanism to improve the efficiency of services.