With the development of economy and the continuous improvement of people's living standards, people pay more attention to the quality of life and health, and then pay more attention to the performance of health system. However, how to further improve the performance of the health service system to meet the growing health service needs of the broad masses of the people has become a topic of general concern. International organizations and scholars from all over the world are actively exploring and studying. Among them, the representative studies are: the performance evaluation method of health service system in the World Health Report 2000 of WHO (1) and the diagnosis theory and method of health service system in the flagship course of health reform and sustainable financing of the World Bank (2). This paper will take the framework of health service system performance evaluation proposed by WHO as the goal, and the diagnostic tools of health service system proposed by the World Bank as the analysis means, and systematically analyze the results, causes and improvement methods and approaches that lead to the low performance of health system in China at present.
1 Health service system performance target
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 category of health system. Its composition includes: preventive health care and medical service providers; Financing intermediary organizations; Drugs, reagents, medical devices, doctors and nurses are put into producers; Health service plans and managers, etc. It can be seen that the health service system has the characteristics of multi-party participation. In this system, they are interrelated, influenced and restricted, and they need to work together to achieve the ultimate goal of the system. Therefore, only when each subsystem works in an orderly and coordinated manner according to the requirements of the ultimate goal of the system can the ultimate goal of the health service system be realized efficiently. However, because different participants have different sub-goals, some of them may even deviate from the ultimate goal of the health service system, so it is difficult to achieve the ultimate goal of the health service system. For example, as the window unit of the health system, the goal of the hospital is obviously consistent with the ultimate goal of the health service system to improve people's health. It should embody the purpose of saving lives and serving the people. All these require the active support and cooperation of each subsystem. We should do it: ask for money, goods and medicine, otherwise, the hospital will inevitably achieve its goals at a discount. As manufacturers of various medical consumables and equipment, although their products can be used to improve health, according to the theory of market economy, their main purpose is to maximize economic benefits. Obviously, the goals of hospitals and enterprises are inconsistent. Due to the complexity of the health service system itself and the characteristics of multi-participation, it is necessary to adopt various ways and methods to achieve the set goals. On the premise of defining its performance objectives, various systems and mechanisms are adopted to ensure that each subsystem serves the ultimate goal of the health service system in a coordinated manner. To this end, we must first further clarify the objectives of the health service system. In its World Health Report 2000, WHO pointed out: Although promoting health is a main goal of the health system, it is not the only goal. The goal of physical health essentially contains two meanings: high quality and minimum difference among individuals. Quality means that the health system can respond appropriately to people's general and reasonable expectations; The smallest difference means fairness. The World Health Report 2002 put forward for the first time in the world that the performance goal of health system should include three aspects: the improvement of health status, the responsiveness to people's reasonable expectations and the fairness of financial contribution. Among them, responsiveness is a brand-new concept, including respect for people and taking the service object as the core. "Respecting people" means respecting clients when seeking medical treatment, and medical staff are polite to others and can protect patients' privacy when checking and treating; Patients have autonomy, can participate in the decision of treatment plan, and have decision-making power; Patients have the right to privacy, and medical institutions can keep medical history and medical reports confidential; Health workers can listen carefully to the statements of customers and their families and communicate with them well. "Taking clients as the core" includes four aspects: medical institutions can pay attention to the needs of clients in time and get medical services quickly when needed; The quality of infrastructure is good, the waiting room has enough space, seats and fresh air, and the facilities are clean, which can provide healthy and delicious food for patients; The clients have the right to choose freely, and they can choose all kinds of medical institutions and medical and health personnel freely; Health institutions have a good social support function, allowing relatives and friends of the parties to visit, and can freely participate in various social activities during hospitalization. Among them, health status and responsiveness indicators are divided into two aspects: level and distribution. That is, it is described from the perspectives of average state and distribution. With this goal in mind, WHO assessed the health service performance of 19 1 member countries. The country with the best health level is Japan, followed by Australia, and France ranks third. Their healthy life expectancy (DALE) is 74.5 years, 73.2 years and 73. 1 year respectively. The top three countries in health distribution are Chile, Britain and Japan. The most responsive country is the United States, followed by Switzerland and Luxembourg. The top two reactivity distributions are the United Arab Emirates and Bulgaria, and 36 countries are tied for third place. Colombia and Luxembourg ranked first and second respectively in terms of financing rights. Based on the above three aspects, the top three countries in the overall performance of health system are Japan, Switzerland and Norway. China ranks 8 1 in horizontal health and101in health distribution; The horizontal reaction and Turkmenistan ranked 88th, and the reactivity distribution and Guyana ranked105th. Financing fairness ranking 188, fourth from the bottom. Overall performance ranking 144. It can be seen that the performance of China's health system is not satisfactory. Why did we get such a result? Using the World Bank's "flagship course of health reform and sustainable financing" health system diagnostic tool, we can systematically analyze the results.
2 China health service system performance analysis
Key factors affecting the performance of health service system
World Bank experts believe that the diagnosis of health system performance should start from five key control points. They are the organization of health system, health financing, payment methods of service providers, supervision and social marketing. They will have an impact on the performance of health system.
First of all, please take a look at the macro-organizational form of China health system and the relationship between subsystems. When it comes to China's health system, people often only refer to the narrow concept, that is, units and individuals that directly provide various medical and health services, such as various hospitals, community health service centers, and disease control centers. However, the influence of health-related units such as medical devices and medical consumables on the intermediate performance of the whole health system is ignored. In fact, after the reform and opening up, the first thing that pushed up the cost of medical services in China was not the cost of medical services, but the price increase of water, electricity, gas and various commodities related to medical services. Even so far, they continue to push up medical costs (of course, other conditions are needed to achieve this cost increase, such as financing, payment and control measures, which we will discuss one by one below). These production units are all economic entities that pursue the maximization of income. In the market economy, their behavior is undoubtedly correct. However, due to the rising medical expenses, medical services need more compensation, otherwise, it will be difficult to achieve its social purpose of serving the people. There are three basic channels for medical service compensation: government, society and individuals. Government input comes from finance, and social input mainly comes from social medical insurance. If the compensation for rising medical expenses cannot be obtained from these two aspects, it can only be obtained from consumers. This will certainly undermine the ultimate performance of the health system-fairness, health, and even the responsiveness of financing. Because, such a financing method will certainly prompt service providers to pay more attention to the response of consumers who have the ability to pay, rather than consumers who have no ability to pay. Because China still lacks a comprehensive management department that can coordinate the interests of all relevant subsystems, in fact, all relevant subsystems have been working hard for their own goals in recent 20 years, ignoring the ultimate performance goal of the health system. Even from the narrow definition of health system, the organization of China's health system is fragmented, and the allocation of resources is obviously disorderly and inefficient. There is still no authoritative management department to coordinate the interests of all parties and implement unified management of responsibilities and rights. The outbreak of SARS in April-May 2003 exposed this defect.
Look at China's health financing model again. In order to enable hospitals to solve the compensation problem on their own, since the 1980s, China has decided to reform the original low-cost charging policy, adopt higher-cost pricing for new technologies and projects adopted by hospitals (the policy of wholesale and retail price difference 15% is still valid), and cross-compensate those medical services whose prices are lower than the cost. Because hospitals must rely on this new policy if they want to survive and develop. Otherwise, the hospital will be difficult to survive and develop. The service goal of the hospital is complex. On the goal of saving lives and serving the people, the goal of pursuing economic benefits and maintaining development has been added. However, it is worth noting that the target of this new financing policy is to serve users. It is based on the premise of losing the fairness of financing in exchange for the survival and development of the health system. Because there are still 80% farmers in China who do not have any form of medical insurance, and they have to pay their own medical expenses. This way of financing will definitely increase their economic burden, so it is not difficult to understand why China's health financing equity ranks fourth from the bottom among 19 1 member countries.
Judging from the payment methods of suppliers, most hospitals in China have been using the oldest payment method for health services, that is, paying by service items. The so-called payment by service item is a method to calculate the prices of different medical service items through a certain method and pay medical service fees according to this price. According to this payment method, the more services provided, the higher the price of each item, and the higher the cost paid to the hospital. The current financing policy and payment system in China determine that the income of health service providers is closely related to the services they provide. Medical providers have a strong economic incentive to sell drugs and provide high-precision equipment inspection items. In addition, due to the asymmetry of medical service information, service providers will inevitably provide excessive medical services.
Let's analyze the control aspect again. Regulation refers to the use of coercive power by the state to change the behavior of residents, including legal provisions promulgated by governments at all levels and mandatory documents for individuals and organizations. Its means include constitution, laws, announcements, orders, regulations and administrative regulations promulgated by the government and non-governmental organizations. The market of health care products is controlled by buyers and sellers of health care products. Supervision is the main tool for the government to improve market defects. Its purpose is to create a good environment for the operation of the medical care market and correct the market failure. Therefore, it is necessary to clarify all kinds of property rights in the field of health, prevent all kinds of fraud and ensure the performance of all kinds of contracts. At the same time, ensure the quality of medical and health services, such as formulating the access system for health manpower, medicines and medical equipment. Facing the pressure of health service affordability, in order to ensure that scarce health resources can be used in areas that can bring the best health effect, technical evaluation of priority health intervention projects should be mandatory, and so on. However, at present, China's control in the field of health is obviously lagging behind, the control of health manpower and capital investment is weak, and the efficiency of human, financial and material allocation is low.
3 China health service system performance analysis
Personal behavior affects the performance and health status of health system in many ways. Changing personal behavior through social marketing to improve health system performance is the fifth key control factor affecting health system performance. In this regard, China has done a good job in the past, and it has been recognized by the international community for a period of time. But recently, we have neglected its importance. SARS once again sounded the alarm for us. Everyone's health habits are not only related to their own individuals, but also affect the health status of the whole population.
To sum up, we can see that the scattered organizational model of health system, inappropriate financing mechanism and payment method, and imperfect control measures are the reasons for the low performance of health system in China. Therefore, in order to improve the performance of the health system, we must fundamentally solve the problem and reform the existing imperfect health system.
3 Countermeasures to improve the performance of China's health service system
3. 1 Implement macro-reform of health system organization. According to the characteristics of the health system, a "Ministry of Health" or a "Ministry of Health and Welfare" should be established to comprehensively coordinate and manage all health-related departments. From the previous analysis, it can be seen that if there is no comprehensive management department to coordinate the interests of all parties, it will inevitably reduce the performance of the entire health system. The experience of China's health reform in the past period also proves that health reform needs the participation and cooperation of many departments. At present, the functions of the Ministry of Health are too narrow, which is not conducive to the optimization of resource allocation in the whole health system. Not only the National Family Planning Commission and the Chinese Medicine Bureau should be brought into the Ministry of Health, but also medical security and population welfare should be brought into the jurisdiction of the Ministry of Health and Welfare, and even the management of drugs and food safety should be brought into its functional scope. Looking at the macro-organization of health systems in countries all over the world, whether it is the UK led by the government, Australia and Canada led by social insurance, or the United States led by the market, the functions of their health departments are broader than those of our current national health departments. This is beneficial for all health-related subsystems to give full play to their respective roles under the guidance of the overall goal of the health system, improve the allocation efficiency of health resources in the whole society, and safeguard social equity and the sustainable development of the health system.
3.2 Reform of health financing mechanism and payment method Although China's current financing mechanism and payment method have played a positive role in alleviating the shortage of funds in the health system in the past period, their shortcomings are becoming more and more obvious. Impairment of the fairness of health financing, and further neglect of the reaction of vulnerable groups to the health system to a certain extent, making the distribution ranking of responsiveness in China as 105 ~ 106. In order to reverse the current inappropriate financing mechanism, firstly, the government should increase investment in health care; Secondly, adjust the price of health service based on cost, so that the relationship between all health service costs and prices is consistent, which can not only reasonably reflect the labor value of health services, but also have no excess profits. Finally, through cross-compensation with high-tech equipment income, the phenomenon that medical service costs are higher than pricing is eliminated. Separate medicine from medicine and cut off the financing mechanism of supporting medicine with medicine. In cities, expand the coverage of social medical insurance; In rural areas, consolidate and develop various forms of rural medical security system. Reform the payment method of all medical security systems, from post-payment system to pre-payment system, and increase the cost awareness of service providers and users.
3.3 Strengthen the control of the health system and create a good environment for the operation of the health care market. Because in the medical service market, consumers lack information to correctly evaluate the quality of medical services, medical service providers are consumers' consumption agents, and there are phenomena of "moral damage" and "write-off" in medical insurance, so the medical care market must be regulated. Measures should be taken to limit the occurrence of service demand induced by suppliers, restrict unqualified service providers from providing services, establish certification standards for medical institutions, control service prices and insurance rates, persist in anti-monopoly and encourage competition, improve the operating mechanism of medical service market and improve service efficiency.