Nordyke Robert J, Peabody John W
International Public Policy and Management Program, School of Policy, Planning and Development, University of Southern California, USA.
Soc Sci Med. 2002 Mar;54(6):939-53. doi: 10.1016/s0277-9536(01)00067-3.
The Republic of Macedonia is undertaking sweeping reforms of its health sector. Funded by a World Bank credit, the reforms seek to improve the efficiency and quality of primary health care (PHC) by significantly strengthening the role of the market in health care provision. On the supply-side, one of the key reform proposals is to implement a capitation payment system for PHC physicians. By placing individual physicians on productivity-based contracts, these reforms will effectively marketize all PHC provision. In addition, the Ministry of Health is considering the sale or concessions of public PHC clinics to private groups, indicating the government's commitment to marketization of health care provision. Macedonia is in a unique position to develop a new role for the private sector in PHC provision. The private provision of outpatient care was legalized soon after independence in 1991; private physicians now account for nearly 10% of all physicians and 22% of PHC physicians. If the reforms are fully realized, all PHC physicians-over 40% of all physicians-will be financially responsible for their clinical practices. This study draws on Macedonia's experience with limited development of private outpatient care starting in 1991 and the reform proposals for PHC, finding a network of policies and procedures throughout the health sector that negatively impact private and public sector provision. An assessment of the effects that this greater policy environment has on private sector provision identifies opportunities to strategically enhance the reforms. With respect to established market economies, the study finds justification for a greater role for government intervention in private health markets in transition economies. In addition to micro-level payment incentives and administrative controls, marketization in Central and Eastern Europe requires an examination of insurance contracting procedures, quality assurance practices, public clinic ownership, referral practices, hospital privileges, and capital investment policies.
马其顿共和国正在对其卫生部门进行全面改革。这些改革由世界银行贷款资助，旨在通过大幅加强市场在医疗服务提供中的作用，提高初级卫生保健（PHC）的效率和质量。在供应方面，关键的改革提议之一是对初级卫生保健医生实施按人头付费制度。通过将个体医生纳入基于生产力的合同，这些改革将有效地使所有初级卫生保健服务市场化。此外，卫生部正在考虑将公立初级卫生保健诊所出售或特许给私人团体，这表明政府致力于医疗服务提供的市场化。马其顿在为私营部门在初级卫生保健服务中发挥新作用方面处于独特地位。1991年独立后不久，私人提供门诊护理就合法化了；现在，私人医生占所有医生的近10%，占初级卫生保健医生的22%。如果改革全面实施，所有初级卫生保健医生——占所有医生的40%以上——将对其临床实践承担财务责任。本研究借鉴了马其顿自1991年以来私人门诊护理有限发展的经验以及初级卫生保健的改革提议，发现整个卫生部门的一系列政策和程序对私营部门和公共部门的服务产生了负面影响。对这一更大政策环境对私营部门服务的影响进行评估，确定了从战略上加强改革的机会。关于成熟的市场经济体，该研究发现转型经济体中政府在私人健康市场中进行更多干预有其合理性。除了微观层面的支付激励和行政控制外，中东欧的市场化还需要审视保险签约程序、质量保证措施、公立诊所所有权、转诊做法、医院特权以及资本投资政策。
