Fiedler John L, Suazo Javier
Social Sectors Development Strategies, Sturgeon Bay, Wisconsin, USA.
Health Policy Plan. 2002 Dec;17(4):362-77. doi: 10.1093/heapol/17.4.362.
Decentralization is commonly championed as a means for achieving equity. To date, however, there has been little discussion of the mechanisms underlying this relationship, and several of the few empirical investigations that have addressed the topic have found the converse; that decentralization has exacerbated inequalities. This article examines the performance and equity in financing of the Honduras Ministry of Health's (MOH) decentralized user fee system. The MOH of Honduras established a national user fee policy in 1989. It provided a framework of rules and regulations and decentralized administration of the system to the regional offices. A survey conducted under the auspices of this study provided detailed information about the structures and operations of MOH user fee systems. The survey revealed that the systems vary markedly by region, creating horizontal inequities, and that they have numerous other shortcomings. The average price of a consultation is low, US dollars 0.16, and revenues have consistently equalled just 2% of MOH expenditures. The systems' administrative costs are equal to 67% of their revenues. Eliminating the user fee systems in all but the national and regional hospitals would actually save money and/or enable the MOH to provide more care. Average consultation prices are highest in health posts, intermediate in centres and lowest in the national hospitals, thereby encouraging the inappropriate use of the MOH's pyramidal referral system and fostering MOH inefficiency. Fee levels and exemption practices are horizontally and vertically inequitable. The likelihood of paying for an ambulatory visit is highest at a health post, 89%, and lowest at a hospital, 49%. Individuals from the poorest one-fifth of households are the most likely to have to pay for care. Honduras' experience demonstrates that a decentralized user fee system is not necessarily equitable, and that, more generally, the gains that can be realized from decentralizing user fee systems are not automatic. They must be anticipated, planned for and cultivated by a well-designed and well-implemented initiative that is not a single, one-time event, but rather a dynamic, on-going enterprise.
权力下放通常被视为实现公平的一种手段。然而，迄今为止，对于这种关系背后的机制鲜有讨论，而且为数不多的几项涉及该主题的实证研究中有几项得出了相反的结论，即权力下放加剧了不平等。本文考察了洪都拉斯卫生部（MOH）权力下放的使用者付费系统在融资方面的绩效和公平性。洪都拉斯卫生部于1989年制定了一项全国性的使用者付费政策。该政策提供了规章制度框架，并将该系统的行政管理权下放到各地区办事处。在本研究主持下开展的一项调查提供了有关卫生部使用者付费系统的结构和运作的详细信息。调查显示，这些系统在不同地区差异显著，造成了横向不平等，而且还有许多其他缺点。一次诊疗的平均价格很低，为0.16美元，收入一直仅占卫生部支出的2%。这些系统的行政成本相当于其收入的67%。除了国家和地区医院外，取消其他所有的使用者付费系统实际上会节省资金，和/或使卫生部能够提供更多的医疗服务。平均诊疗价格在卫生站最高，在医疗中心居中，在国家医院最低，从而促使人们不恰当地使用卫生部的金字塔式转诊系统，造成卫生部效率低下。收费水平和豁免做法在横向和纵向都不公平。在卫生站进行门诊付费的可能性最高，为89%，在医院最低，为49%。最贫困的五分之一家庭的成员最有可能需要支付医疗费用。洪都拉斯的经验表明，权力下放的使用者付费系统不一定公平，而且更普遍地说，从权力下放的使用者付费系统中能够实现的收益并非是自然而然的。必须通过精心设计和妥善实施的举措来预见、规划和培育这些收益，这不是一个单一的一次性事件，而是一个动态的持续过程。
