Sheaff Rod
National Primary Care Research and Development Centre, Manchester University, Williamson Building, Oxford Road, Manchester, M13 9PL, UK.
Soc Sci Med. 2005 May;60(10):2359-69. doi: 10.1016/j.socscimed.2004.10.008. Epub 2004 Dec 9.
Epidemiological, demographic and environmental crises, transition to a new political regime and exceptionally severe economic crises were powerful stimuli to health sector reform in Russia. The Russian Federation responded by introducing medical insurance whilst decentralising public administration. Yet despite intense contextual pressures to do so and a new policy climate, Russian hospitals found it difficult to reprofile services and reallocate their resources. A case study analysing governance structures in Sverdlovsk oblast reveals that medical insurance created incentives to reduce costs by reducing bed-days, but if hospitals did so they would lose money under the formulae through which decentralised local government still allocated around three-quarters of hospital income. If instead hospitals tried to increase budgetary income by increasing numbers of bed-days, the insurance system would penalise them. This specific form of policy mess can be called 'governance in gridlock'. The juxtaposition of two overlapping but incompatible sets of governance structures practically immobilised official hospital management systems. It is as one-sided to blame residues of the Soviet system for this gridlock as it is to blame the medical insurance system. Gridlock resulted from the interaction of the two, a problem to which all health system reform is potentially vulnerable.
流行病学、人口统计学和环境危机、向新政治体制的过渡以及异常严重的经济危机，都是俄罗斯卫生部门改革的强大刺激因素。俄罗斯联邦的应对措施是引入医疗保险，同时下放公共管理权力。然而，尽管面临这样做的巨大背景压力和新的政策环境，俄罗斯医院发现很难重新规划服务并重新分配资源。一项对斯维尔德洛夫斯克州治理结构进行分析的案例研究表明，医疗保险促使医院通过减少住院天数来降低成本，但如果医院这样做，根据地方政府下放权力后仍用于分配约四分之三医院收入的公式，它们将会亏损。相反，如果医院试图通过增加住院天数来增加预算收入，保险系统将会对它们进行惩罚。这种特殊形式的政策困境可被称为“治理僵局”。两套重叠但不相容的治理结构并存，实际上使官方医院管理系统陷入了瘫痪。将这种僵局归咎于苏联体制的残余部分，与归咎于医疗保险系统一样片面。僵局是两者相互作用的结果，这是所有卫生系统改革都可能面临的一个问题。
