Collins D, Quick J D, Musau S N, Kraushaar K, Hussein I M
Management Sciences for Health, Boston, USA.
Health Policy Plan. 1996 Mar;11(1):52-63. doi: 10.1093/heapol/11.1.52.
The combined effects of increasing demand for health services and declining real public resources have recently led many governments in the developing world to explore various health financing alternatives. Faced with a significant decline during the 1980s in its real per capita expenditures, the Kenya Ministry of Health (MOH) introduced a new cost sharing programme in December 1989. The programme was part of a comprehensive health financing strategy which also included social insurance, efficiency measures, and private sector development. Early implementation problems led to the suspension in September 1990 of the outpatient registration fee, the major revenue source at the time. In 1991, the Ministry initiated a programme of management improvement and gradual re-introduction of an outpatient fee, but this time as a treatment fee. The new programme was carried out in phases, beginning at the national and provincial levels and proceeding to the local level. The impact of these changes was assessed with national revenue collection reports, quality of care surveys in 6 purposively selected indicator districts, and time series analysis of monthly utilization in these same districts. In contrast to the significant fall in revenue experienced over the period of the initial programme, the later management improvements and fee adjustments resulted in steady increases in revenue. As a percentage of total non-staff expenditures, fiscal year 1993-1994 revenue is estimated to have been 37% at provincial general hospitals, 20% at smaller hospitals, and 21% at health centres. Roughly one third of total revenue is derived from national insurance claims. Quality of care measures, though in some respects improved with cost sharing, were in general somewhat mixed and inconsistent. The 1989 outpatient registration fee led to an average reduction in utilization of 27% at provincial hospitals, 45% at district hospitals, and 33% at health centres. In contrast, phased introduction of the outpatient treatment fee beginning in 1992, combined with somewhat broader exemptions, was associated with much smaller decreases in outpatient utilization. It is suggested that implementing user fees in phases by level of health facility is important to gain patient acceptance, to develop the requisite management systems, and to orient ministry staff to the new systems.
对卫生服务需求不断增加以及实际公共资源不断减少的综合影响，近来促使许多发展中国家的政府探索各种卫生筹资替代方案。肯尼亚卫生部在20世纪80年代人均实际支出大幅下降后，于1989年12月推出了一项新的费用分担计划。该计划是一项全面卫生筹资战略的一部分，该战略还包括社会保险、效率措施和私营部门发展。早期实施问题导致当时的主要收入来源——门诊挂号费于1990年9月暂停收取。1991年，卫生部启动了一项管理改进计划，并逐步重新引入门诊费用，但这次作为治疗费。新计划分阶段实施，从国家和省级层面开始，然后推进到地方层面。通过国家收入收集报告、对6个有针对性选择的指标地区进行的护理质量调查以及对这些地区每月利用率的时间序列分析，评估了这些变化的影响。与初始计划期间收入大幅下降形成对比的是，后来的管理改进和费用调整使收入稳步增加。据估计，在1993 - 1994财政年度，省级综合医院的收入占非工作人员总支出的比例为37%，小型医院为20%，保健中心为21%。总收入中约三分之一来自国家保险理赔。护理质量指标虽然在某些方面因费用分担而有所改善，但总体上有些好坏参半且不一致。1989年的门诊挂号费导致省级医院的利用率平均下降27%，地区医院下降45%，保健中心下降33%。相比之下，1992年开始分阶段引入门诊治疗费，并伴有更广泛的豁免，门诊利用率的下降幅度要小得多。有人认为，按卫生设施级别分阶段实施使用者付费对于获得患者接受、建立必要的管理系统以及使卫生部工作人员适应新系统很重要。
