Public financial investment in medical and health security: effectiveness and policy path
Abstract: At present, basic medical care is one of the fields to improve people's livelihood. The economic and social nature of basic medical and health services determines that the investment in its protection is an important part of people's livelihood finance. Under the realistic constraints of government financial resources and investment scale, the effectiveness of public financial investment should be the focus of attention. As the main mechanism of medical and health resources allocation, public finance must adjust the investment structure and implement effective policies and measures to ensure the fairness and efficiency of medical and health resources allocation from both supply and demand.
Keywords: medical and health security; Public financial input; Validity; Policy path
China Library Classification Number: FS 10 Document Identification Number: A Document Number:1000-176 X (2010) 01-0089-05.
First of all, the questions raised
Medical and health services can be divided into two aspects: first, public health services, such as immunization and infectious disease prevention; The other is general medical service, that is, the diagnosis and treatment of individual diseases. In modern society, no government completely allows market forces to solve the problem of medical and health services, but all intervene in the field of financing and security through public finance. The main reason is that public health service has obvious external effects, with the characteristics of increasing returns to scale and public goods; However, general medical service has the characteristics of uncertainty, information asymmetry, moral hazard, adverse selection and possible induced consumption, which leads to? Market failure? And sub-optimal supply level. More importantly, people generally regard receiving necessary medical and health services as a basic human right, which meets the requirements of basic social values. This view is supported by public expenditure in most countries? The expansion of the health care system and the popularization of personal access to medical services at low cost? Can prove it.
Although government intervention can be corrected to some extent? Market failure? However, will there be intervention to promote social welfare? Failure? . How did the government intervene in the medical and health market during the transition of China? Absence? This is one of the important factors leading to the unsuccessful reform of the medical and health system. Therefore, in order to realize the party's? Seventeenth National Congress? Put forward? Is there a doctor who can treat this disease? To achieve the goal of people's livelihood, we must reasonably position and effectively play the leading role of the government in assuming the responsibility of universal medical security.
The government's intervention in the medical and health field is mainly achieved through government health expenditure (that is, all public resources used by the government to carry out medical and health activities), and accordingly, medical and health security is transformed into public financial input. In what way should the government assume the responsibility in the field of medical and health care? To what extent? Leading to this problem in China? Government-led faction? And then what? Market competitors? Different views. Are you online? Government-led faction? It seems that the government should invest more in the medical service delivery system, control the medical service delivery system, and bear the investment of the medical department and the salary of the medical staff, so as to urge them to provide basic medical and health services to the public free of charge or at reduced fees, thus reducing the medical burden of the public. Are you online? Market competitors? I think so. The government should invest in the social medical insurance system, organize the construction of the social medical insurance system by providing subsidies to the low-income class, and promote the competition of the medical service delivery system to improve efficiency. The above-mentioned viewpoint is biased in that it focuses on analyzing the scale and investment of public finance investment from the perspective of financing, while ignoring the performance research of investment. Judging from the scale of government health expenditure in China, with the coordinated development of social economy and the transformation of government functions, the government's investment in health has been increasing, and the proportion of government health investment in the total social health financing has begun to rise. Since the end of 1990s, some key indicators have been close to South Korea and ahead of India, which shows that government health expenditure has a certain scale under consistent comparison. According to the Research Report on Total Health Expenditure in China in 2006 issued by the Institute of Health Economics of the Ministry of Health, from 65438 to 2005, the average annual growth rate of total health expenditure was 1 1.47%, slightly faster than the GDP growth rate. During 2008 1 ~ 1 1, the national fiscal revenue was 5806825438+0 billion yuan, a year-on-year increase of 20.5%. The national fiscal expenditure was 4,582.534 billion yuan, an increase of 23.6%; Medical and health expenditure 1, 948,438+0 billion yuan, an increase of 37.3%.
However, while the scale of government health expenditure continues to expand, China's medical and health security has not effectively formed a fair and efficient mechanism. Since the 1990s, the utilization efficiency and fairness of medical and health resources have shown a downward trend, which is mainly reflected in the extraordinary rapid growth of medical expenses, unfair burden of medical expenses, declining medical accessibility of low-income people, limited improvement of medical service level, negative expectations of most residents on medical problems, and the inability of medical and health resources supply to effectively meet individual medical and health needs. Visible, in order to achieve? Establish a universal medical security system to ensure that everyone enjoys basic medical security? The goal is that while the government's medical and health investment is increasing, the direction of public policy should be from? Expand investment? Turn? Effective investment? Pay more attention to the effectiveness of public financial investment and its policy effect, and improve the target efficiency of government medical and health funds.
Two, the judgment of the effectiveness of public financial investment in medical and health care
In the supply and demand chain of health care, public financial input will have a direct impact on supply and demand (as shown in figure 1). On the one hand, public financial input is transformed into public health resources, forming the supply of medical and health goods and services; On the other hand, it forms direct subsidies to individuals and subsidies to medical insurance institutions, which further affects the choice of medical and health needs. Because the individual's demand for medical and health care is a derivative demand, obtaining medical and health services is the fundamental way to meet health needs. Therefore, the logical scale to measure the effectiveness of supply and demand is that the medical and health supply formed through public financial investment can meet the residents' demand for effective medical and health services and achieve the expected health improvement goal.
From the supply point of view, the effectiveness of public financial input is the unity of efficiency and fairness in the allocation of medical and health resources, which should include four basic dimensions: (1) From the economic point of view, ensure the effective provision of medical and health services with the nature of public goods and external effects, and avoid the net loss of social welfare. (2) The rational allocation of medical and health resources under the established budget maximizes the marginal output of medical and health expenditure. In other words, homogeneous medical and health services or commodities should be obtained at the lowest possible cost, or the unit expenditure can form the largest number of medical and health services. (3) Coordinated allocation of medical resources. It is manifested in different areas, different levels and different medical and health projects, so as to minimize the dislocation of resource allocation in the investment direction and avoid the idleness and waste of resources. (4) The efficiency and quality of medical and health service supply can form an effective medical and health demand.
The effect of China's public financial medical and health investment on improving residents' health level is not obvious, which is mainly manifested in the fact that medical and health resources are mainly invested in large and medium-sized hospitals in cities, and grass-roots health institutions are short of funds to prevent the imbalance between resources and medical resources. In the invested projects, more investment is in fixed assets, ignoring the improvement of the quality of health personnel and medical and health services. According to the analysis of "Research Report on Total Health Expenditure", from 1990 to 2005, the proportion of urban hospitals in total health expenditure basically maintained an upward trend, from 32.76% to 50.09%; The proportion of county hospitals and township hospitals in health expenditure decreased obviously, especially the proportion of township hospitals decreased from 10.62% to 6.26% year by year. Such resource allocation has caused imbalance between urban and rural areas, between regions, between prevention and control, and great differences in the interests of different social groups. Because the people who make high use of hospitals (especially high-level hospitals) are mainly high-income residents living in cities, rural or low-income people are restricted by various conditions and cannot make full use of this part of resources. In this sense, the overall effect of medical and health investment is not good, and the impact on the health of most people is relatively small.
Under the condition that the public finance medical and health investment budget is established, the effectiveness of investment also depends on the efficiency and quality of service supply of public medical and health departments. Efficient and high-quality medical and health services are the transmission and transformation mechanism of investment and realization of health improvement goals. If the management efficiency of medical and health institutions is low, or medical and health institutions
Residents' accessibility, availability and satisfaction with medical and health services will decline. Judging from the reality of rural medical and health security in China, although most provinces and cities in China have basically realized the existence of hospitals in towns and villages, it is difficult for farmers to increase the stock of health capital through medical and health services provided by the government because of poor medical equipment and low quality of medical personnel. In addition, poor service quality will also lead to medical detours (patients choose higher costs, such as distant and expensive medical institutions for treatment), further reducing the utilization of public medical facilities and resources. From the demand side, the effective impact of public financial medical and health investment on demand is: by reducing the opportunity cost of residents' demand, improving residents' ability to purchase medical and health services and maximizing the service quality coupled with demand. Based on this, the public financial input mechanism is designed.
1 Reasonably determine the proportion of expenses borne by the government and individuals.
Medical and health expenses are the decisive factor of residents' medical and health needs, especially for low-income groups. Judging from the situation of countries around the world, the level of residents' medical and health needs is inversely proportional to the level of medical and health expenses borne by individuals. The higher the proportion of private medical care, the smaller the influence of government expenditure on personal needs. If government expenditure can't reduce the burden of personal medical and health needs, then government investment can't guide effective demand. Worldwide, although the medical and health expenses borne by individuals in low-income countries are very high, residents' demand for medical and health care is far lower than that of residents in high-income countries, because the latter can obtain services provided by public medical and health departments free of charge or at a lower price. In the composition of total health expenditure in China, the government budget health expenditure decreased from 25. 1% in 1990 to 20.3% in 2007, while the personal cash health expenditure increased from 35.7% in 1990 to 45.2% in 2007. Therefore, although the income level of residents is constantly improving, the personal demand for medical care is constantly decreasing, and residents' evasive behavior towards public medical institutions is intensifying, which is also an important reason for the lack of domestic demand in China.
2 moderately define the scope of medical and health protection
The coverage of medical and health security system includes basic medical care and public health. There is a positive correlation between the demand price elasticity of different medical and health projects and the influence of government investment on individual demand. Therefore, policy makers should purposefully choose intervention areas according to the elasticity of individual medical and health needs. Generally speaking, for basic medical and health services, such as serious illness or serious illness, individuals are insensitive to the changes of factors affecting the price and accessibility of these services, while preventive services have higher demand elasticity than curative services.
From the perspective of increasing demand, it is a feasible choice to increase investment in medical care and preventive services. However, due to the fair idea of increasing the demand of low-income people, under the condition of limited government financial resources and management ability, the focus of public financial investment should also be placed on projects with low demand elasticity, because the medical and health payment ability of low-income people is strictly limited by income budget, and often concentrated on projects with low demand elasticity.
3. Correctly consider the factors affecting medical and health needs.
Personal demand for medical care is composed of many factors, among which the main factors include income level, medical insurance system and employment status. In addition, the characteristics of medical and health institutions (medical and health accessibility, accessibility, medical and health personnel, medical and health expenses, waiting time, etc. ) is also an important variable affecting personal medical and health needs. The high income level, sound medical insurance system and good employment situation directly determine the high demand for medical and health care, and the possibility and feasibility of obtaining medical and health resources increase. On the contrary, it will inhibit the demand for medical and health services of low-income people, self-funded medical care and laid-off workers to a certain extent. The research shows that the increase of urban residents' family income 10% will increase their demand probability for medical and health institutions, reduce the probability of self-treatment (from 4 1.82% to 36.98%), and their demand for hospitals above the municipal level will also increase greatly, with a relative growth rate of about 15%. After the household income of rural residents increased by 10%, the probability of patients choosing medical and health institutions at or above the county level increased by 15% and 38. 1 1% respectively. By increasing the proportion of urban residents' basic medical insurance and the proportion of new rural cooperative medical workers, the demand for public hospitals will increase obviously, while the demand for private institutions and self-treatment will decrease. However, due to the great differences between the two types of insurance in terms of scope, nature and compensation amount, the incremental effect of the new rural cooperative medical system on personal medical and health needs is lower than that of urban basic medical insurance, and the probability of self-treatment of the former is reduced by 9.9%, while that of the latter is reduced by 33.2%.
The above analysis shows that the public * * * financial health investment is only a variable that affects individual health needs. When formulating policies to improve the effectiveness of government medical and health expenditure or provide effective medical and health services, it is necessary to comprehensively consider other relevant public financial policies, such as income distribution policy, social security system, fiscal and taxation policies to promote employment, etc., and bring them into the policy system to effectively improve medical and health needs, and all policies should be coordinated.
Third, the adjustment of public finance investment structure and the choice of policy path.
In the case of a certain scale of public financial investment, the feasible way to solve the contradiction between the finiteness of public financial investment and the infinity of residents' medical and health needs is to adjust the structure of public medical and health resources reasonably according to the actual situation, and completely change the public financial expenditure mode of emphasizing investment, neglecting output, emphasizing scale and neglecting performance. This is of great practical significance for meeting the new round of medical and health system reform, ensuring basic people's livelihood, increasing consumption rate, promoting economic growth and improving the stability and sustainability of economic operation in the current economic crisis.
1 Improve the medical and health service system
The establishment of medical and health service system must be the responsibility of the government. The government should keep or even improve some public medical and health institutions with reasonable layout, high accessibility and low cost, mainly to solve the basic medical problems of poor people and ordinary residents. In view of the unreasonable layout of China's current medical and health service system, what should be the policy orientation of public financial investment? Grab a little and zoom in? , focusing on supporting the construction of urban community health service centers, health service stations, township hospitals and central hospitals. Community health service institutions are the core of urban residents' primary health prevention and medical treatment, and play a huge role in meeting the basic medical and health needs of urban residents. Strive to achieve full coverage of urban community health services in 3-5 years. The services of township hospitals are mainly oriented to rural areas, representing rural medical and health resources and closely related to farmers' basic medical and health needs. By increasing the investment in infrastructure such as medical equipment and business rooms in hospitals in rural areas, we can improve farmers' medical conditions and medical environment, effectively change the negative growth in the construction of township hospitals, and enhance the accessibility and accessibility of rural residents' medical care. 2. Promote the equalization of basic medical and health services between regions. As an important part of human capital investment, equalization of medical and health investment requires all members of society to have equal opportunities, quantity and quality to obtain and enjoy basic medical and health services regardless of their ability to pay. The change of China's financial system and the implementation of local fiscal decentralization policy have had a negative impact on the equalization of basic medical and health services between different regions. The widening gap between local economic development levels has led to the widening gap between basic medical and health development. Therefore, it is necessary to reform the financial relationship between the central and local governments, so that the medical and health expenditure responsibilities of governments at all levels can match their financial resources. The responsibility of the central government is to improve the fairness of basic medical and health services, and to narrow the differences of basic medical and health services in different places by improving the central and local financial transfer payment systems. The responsibility of local governments is to improve the level of local basic medical and health services, make full use of the advantages of fiscal decentralization, and study and establish basic medical and health service standards suitable for local characteristics. In the design of transfer payment system, we should make full use of science? Factor method? To improve the allocation capacity of basic medical and health resources between regions and improve the sociality, public welfare and welfare of basic medical and health undertakings, we should comprehensively consider the local tax revenue capacity, the scarcity of medical and health resources, the level of providing effective services, the needs of residents with different income levels and the improvement of the overall health level of residents.
3. Establish a long-term financing mechanism for the new rural cooperative medical insurance.
The government can provide basic medical security for residents in two ways: first, invest in the supply side to strengthen the construction of public medical and health institutions; The other is to subsidize the demand side, and establish a social medical insurance system by subsidizing the insured. In recent years, some countries (such as Britain) have carried out reforms from investing in medical and health service institutions to purchasing medical and health services, aiming at introducing market competition mechanism into the medical and health service delivery system, providing economic compensation according to the effect of medical services, encouraging medical and health service institutions to change from profit-oriented to ensuring the health of residents, and better respecting the right of demanders to choose medical and health services. At the same time, in the case of limited financial resources, it is convenient to subsidize the demand side with financial input and take care of specific groups, such as the poor, thus promoting health equity. According to this idea, China's new rural cooperative medical system is a voluntary and non-profit medical insurance established by using central and local financial subsidies to guide residents to participate in insurance.
The effectiveness of the new rural cooperative medical system largely depends on the design of financing mechanism. Follow? Government guidance and support, collective support and individual investment? The principle of financing, governments at all levels attach importance to and increase the proportion of financial subsidies to the new rural cooperative medical system, which is an important guarantee to reduce the cost of collective and individual financing. In order to make financial subsidies scientific and standardized, we must weigh the medical and health needs of local rural residents, the level of social and economic development and the affordability of individual and collective economy, and adopt various forms of medical security according to the economic situation of rural areas in different regions. For example, in poor rural areas, state and collective investment is the main investment, supplemented by individual investment, and the semi-accumulation and semi-cash system is adopted; In wealthy rural areas, the fund system should be adopted, and individual accumulation should be used to form funds to establish a stable source of medical security funds. Another issue related to the financing mechanism is to maximize coverage. What is the feasible choice to solve this problem? Implicit coercion? The implementation of this system can reduce the management cost of the new rural cooperative medical system, enhance the fund overall planning ability, improve the compensation level and farmers' ability to resist the risk of serious illness, so that the insured farmers can get the maximum benefit from it, and then attract more farmers to join the new rural cooperative medical system.
4 Standardizing the Public Health Service Voucher System For a long time, public health services in China have been provided by public health institutions or state-owned hospitals with compensation. The clients not only have to pay certain service fees to these institutions, but also the government's public health funds are not directly subsidized to the heads, but are subsidized to public health institutions in the form of personnel funds and work funds. In this case, there is no sense of competition among health institutions, and residents simply have no right to choose, which is also the reason for the status quo. Difficult and expensive to see a doctor? One of the reasons. Public health service vouchers are government funds for public health services. Vouchers? In the form of subsidies? Boss? , not only make residents become independent consumers of public health services, make health institutions become independent producers of public health services, but more importantly, promote fair competition among health institutions, eliminate the fittest and improve the service efficiency of the medical market. As a financial expenditure system, the essence of public health service voucher is to change from public financial input to public health service purchase, from supply side to demand side, from? Raising people? Change to? Raising things? , reasonable, efficient and fair allocation of medical and health resources.