Liu Xingzhu, Mills Anne
Institute of Social Medicine and Health Policy, Shandong Medical University, Jinan, People's Republic of China.
Soc Sci Med. 2002 Jun;54(11):1691-8. doi: 10.1016/s0277-9536(01)00337-9.
Financing reforms of China's public health services are characterised by a reduction in government budgetary support and the introduction of charges. These reforms have changed the financing structure of public health institutions. Before the financing reforms, in 1980, government budgetary support covered the full costs of public health institutions, while after the reforms by the middle of the 1990s, the government's contribution to the institutions' revenue had fallen to 30-50%, barely covering the salaries of health workers, and the share of revenue generated from charges had increased to 50-70%. These market-oriented financing reforms improved the productivity of public health institutions, but several unintended consequences became evident. The economic incentives that were built into the financing system led to over-provision of unnecessary services, and under-provision of socially desirable services. User fees reduced the take-up of preventive services with positive externalities. The lack of government funds resulted in under-provision of services with public goods' characteristics. The Chinese experience has generated important lessons for other nations. Firstly, a decline in the role of government in financing public health services is likely to result in decreased overall efficiency of the health sector. Secondly, levying charges for public health services can reduce demand for these services and increase the risk of disease transmission. Thirdly, market-oriented financing reforms of public health services should not be considered as a policy option. Once this step is made, the unintended consequences may outweigh the intended ones. Chinese experience strongly suggests that the government should take a very active role in financing public health services.
中国公共卫生服务的筹资改革特点是政府预算支持减少并引入收费。这些改革改变了公共卫生机构的筹资结构。在筹资改革之前，1980年政府预算支持涵盖了公共卫生机构的全部成本，而改革后到20世纪90年代中期，政府对机构收入的贡献已降至30%-50%，仅够支付卫生工作者的工资，收费产生的收入份额则增至50%-70%。这些以市场为导向的筹资改革提高了公共卫生机构的生产率，但一些意外后果也变得明显。筹资体系中的经济激励措施导致不必要服务的过度提供，以及社会所需服务的供应不足。使用者付费减少了具有正外部性的预防服务的接受度。政府资金的缺乏导致具有公共物品特征的服务供应不足。中国的经验为其他国家提供了重要教训。首先，政府在公共卫生服务筹资中作用的下降可能导致卫生部门整体效率降低。其次，对公共卫生服务收费会减少对这些服务的需求，并增加疾病传播风险。第三，公共卫生服务以市场为导向的筹资改革不应被视为一种政策选择。一旦迈出这一步，意外后果可能会超过预期后果。中国的经验有力地表明，政府应在公共卫生服务筹资中发挥非常积极的作用。
