Robertson R L, Castro C E, Gomez L C, Gwynne G, Tinajero Baca C L, Zschock D K
Mount Holyoke College, South Hadley, MA 01075.
Soc Sci Med. 1991;32(12):1327-36. doi: 10.1016/0277-9536(91)90192-f.
This study of costs, quality and financial equity of primary health services in Ecuador, based on 1985 data, examines three assumptions, common in international health, concerning Ministry of Health (MOH) and Social Security (SS) programs. The assumptions are that MOH services are less costly than SS services, that they are of lower quality than SS services, and that MOH programs are more equitable in terms of the distribution of funds available for PHC among different population groups. Full costs of a range of primary health services were estimated by standard accounting techniques for 15 typical health care establishments, 8 operated by the MOH and 7 by the rural SS program (RSSP), serving rural and peri-urban populations in the two major geographical regions of Ecuador. Consistent with the conventional premise, MOH average costs were much lower than RSSP costs for several important types of services, especially those provided by physicians. Little difference was found for dental care. The lower MOH physician service costs appeared to be attributable primarily to lower personnel compensation (only partially offset by lesser productivity) and to greater economies of scope. Several measures of the quality of care were applied, with varying results. Based on staff differences and patterns of expenditures on resource inputs, notably drugs, RSSP quality appeared higher, as assumed. However, contrary to expectation, a questionnaire assessment of staff knowledge and procedures favored the MOH for quality. Program equity was judged in terms of per capita budgeted expenditures (additional measures, such as the likelihood of receiving necessary care, would have required household survey data beyond the scope of this program-based study). The results support the assumption of greater MOH financial equity, as its program reveals less variation in budgeted expenditures between different population groups covered. Additional evidence of equity, using other indicators, would be helpful in future research. The paper's findings have policy implications not only for Ecuador's health sector but also for policy-makers in other countries at similar levels of socioeconomic development. These implications are spelled out in order to guide officials wrestling with issues of efficiency, quality, and equity as they search for the best use of scarce resources to promote health.
这项基于1985年数据对厄瓜多尔初级卫生服务的成本、质量和财务公平性进行的研究，检验了国际卫生领域中关于卫生部（MOH）和社会保障（SS）项目的三个常见假设。这些假设是，卫生部的服务成本低于社会保障的服务成本，其质量低于社会保障的服务质量，并且卫生部的项目在初级卫生保健可用资金在不同人群中的分配方面更具公平性。通过标准会计技术估算了15个典型医疗机构一系列初级卫生服务的全部成本，其中8个由卫生部运营，7个由农村社会保障项目（RSSP）运营，服务于厄瓜多尔两个主要地理区域的农村和城市周边人口。与传统观点一致，在几种重要的服务类型中，尤其是医生提供的服务，卫生部的平均成本远低于农村社会保障项目的成本。牙科护理方面差异不大。卫生部较低的医生服务成本似乎主要归因于较低的人员薪酬（仅部分被较低的生产率所抵消）和更大的范围经济。应用了几种护理质量衡量标准，结果各不相同。基于人员差异和资源投入（特别是药品）的支出模式，正如所假设的那样，农村社会保障项目的质量似乎更高。然而，与预期相反，对工作人员知识和程序的问卷调查评估在质量方面更倾向于卫生部。项目公平性是根据人均预算支出判断的（其他衡量标准，如获得必要护理的可能性，将需要超出本基于项目的研究范围的家庭调查数据）。结果支持了卫生部在财务方面更具公平性的假设，因为其项目显示在覆盖的不同人群之间预算支出的差异较小。使用其他指标的额外公平性证据将有助于未来的研究。本文的研究结果不仅对厄瓜多尔卫生部门具有政策意义，对其他处于类似社会经济发展水平的国家的政策制定者也具有政策意义。阐述这些意义是为了指导在寻求最佳利用稀缺资源促进健康时应对效率、质量和公平问题的官员。
