中国医革向何处去？ China Health Reform at Crossroad

1. 中国医革向何处去？China Health Reform at Crossroad 刘国恩 博士 Gordon G. Liu, PhD. 北京大学光华管理学院 卫生经济与管理学系 教授，系主任 Email: ggliu@unc.edu; gordon@gsm.pku.edu.cn Seminar at Peking Union Medical College, Sep 18, 2006

2. 演讲内容 • 发生了什么根本问题 • 产生问题的本质原因 • 科学发展观探讨问题

3. “看病难-看病贵” 当今中国面临的首要社会现象

4. 中国 –世界成长最快的转型经济China – the Fastest Transitional Economy source: WDI online database, World Bank, 2005

5. 中国 –世界强大经济体之列China – Leading Economy in the World Source: www.worldbank.org

6. 80年代的人均期望寿命LE in 1980: a global over-achiever (Eggleston 2004)

7. 20年后的人均期望寿命LE in 2000: median performer (Eggleston 2004)

8. 80年代初的婴儿死亡率IFM in 1980: a global over-achiever (Eggleston 2004)

9. 20年后的婴儿死亡率IMR in 2000: median player (Eggleston 2004)

10. 期望寿命的相对变化LE: China vs. Rest of the World

11. 婴儿死亡率的相对变化IMR: China vs. Rest of the World

12. 问题可能出在哪里？Possible Diagnoses

13. 卫生总开支并不小Total Spending is SIZABLE China Total Health Expenditure as % of GDP % 6.00 5.00 4.00 3.00 Year 2.00 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

14. 其他国家总开支状况GDP % on Health by Other Nations Source: OECD Health Data 2002

15. 政府投入持续下降Government Spending on Health 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Year 0% 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Government health appropriation Social health expenditure Out-of-pocket health expenditure

16. 其他国家政府投入高Health Spending in OtherNations

17. 中央与地方财政投入

18. 共识一：国家健康投入太少 • 需方筹资问题(Financing) • 降低基本医疗服务的可及性，尤其是贫困人群 • 负面改变个人就医行为，加大“抗、拖、重”程度 • 供方服务问题(Organization) • 质量降低？ • 垄断价格？(P>>MC)

19. 有限资源的不公平分配Inequitable Financing Scheme Rural Urban

20. 500 400 300 200 Urban Rural 100 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 城乡卫生服务使用的差距Severely Under-served Care for the Rural WHO report (2000): 188th of 191 WHO member nations in terms of equity MOH Report 40-60% of Rural Pop did not seek care due to financial barrier; leading to over 60% of deaths died home without care

21. 边际报酬递减律 Grossman Health Production Function (1972) 365 days Healthy days Hmin Health Stock Investment

22. 共识二：资源配置低效 • 高端医院 “吃不完” – 价格飞涨 • 低端机构 “吃不饱” – 闲置倒闭 加剧了看病难-看病贵问题

23. 低效的服务支付模式Inefficient Reimbursement Model Fee-for-Service Model • Pre-reform Era: FFS was NOT a significant issue due to lack of incentives for service providers • Post-reform Era: FFS serves as a major driving force for the over-use of care or induced demand in response to the strong economic incentives

24. 扭曲的市场竞争条件Distorted Market Competitive Conditions • Public Hospital Providers • Government subsidy for wages • Tax free advantages • Service price regulation • Private Hospital Providers • No government subsidies • High tax rates • Other unfair market barriers Difficult care Expensive care 看病难 看病贵

25. 共识三：缺乏竞争激励机制 • 国营机构“一统天下”，缺乏有效竞争和激励机制，使得垄断价格从可能成为现实； • 而卫生服务市场的信息不对称： • 垄断作业与寻租价格程度更为严重

26. 公-民营医院医疗费用对比 数据来源：浙江省温州市卫生经济学会 2004

27. 科学发展观与战略选择

28. 发展战略I - 健康投资 Controlling for other factors, pure health effect on GDP growth is about 1.4% for every 13 years in life expectancy (Barro and Sala-i-Martin 1995) WHO study (2001): each 10% improvement in LE leads to 0.3-0.4% in economic growth, controlling for other conditions Macro studies:Bloom and Sachs 1998; Bloom and Canning 2000; Bhargava et al. 2001; Bloom, Canning, and Sevilla 2001); Bhargava, Jamison, Lau, and Murray, 2001 Micro studies:Strauss and Thomas 1998; Glick and Sahn 1998; Schultz 1999, 2001, 2002;

29. 健康投资=人力资本基石 • Demand for Health (Grossman 1972) offers more specific insights on the dual roles of health • consumption purpose • investment purpose Human Capital Theory (Becker 1965) Becker G., Econ J., 1965, 75(299): 493-517; Grossman M., JPE, 1972, 80(2): 223-255.

30. 健康的高收入弹性 • Income-health elasticity • 1.6 (health) • 1.6 (education) • 0.7 (house) • 0.3 (cloth) • 0.2 (food) • 1.1 (others) UK case: 20-30% of the income growth (1780-1979) attributable to health and nutrition improvement)

31. 健康与经济增长 –描述统计

32. 基于中国的证据

33. 健康投资的收入回报 1989-1995 Data

34. 健康投资的收入回报 1989-1995 Data

35. 国家发展战略：全民健保 发展战略II –全民健保 • 经济理论支持 • 符合政府干预弥补市场失灵对公共卫生和贫穷人群的照顾；边际效益理论 • 政治伦理价值 • “以人为本”的治国方针；实现中国“人人健康”目标的承诺 • 国际实践：泰国范例 • 美国《独立宣言》：life, liberty, and pursuit of happiness • 机构良性循环 • 有效初级卫生需求增加；促进初级医疗机构和人员发展的良性循环；有利区域卫生规划。

36. 全民健保筹资可行性

37. 财政盈余/赤字的变化

38. 中央财政 初级保健 基本医疗 单位补助 个人负担 财政政策 专业支持 地方财政 有效筹资-开支模式 差异支付

39. 发展战略III –管理竞争 • 政府垄断 – 低效、寻租、腐败的温床 • 政府的“三只手”功能：无为；扶持；掠夺 • 管理竞争模式 (Managed Competition) • 市场竞争 – 效率目标 （服务组织） • 政府干预 – 公平目标 （服务筹资） • 激励相容的合同 • Doctors hold a key of success • Contracting with compatible incentives!!!!

40. Incentive Matters “If health-care providers are reimbursed on the basis of how healthy their patients are, then they will have enormous incentives to do all the right things” Larry Summers (2004) – 哈佛大学前任校长