Institute of Health and Human Development, University of East London, Stratford Campus, Romford Road, London E15 4LZ, UK.
Health Policy Plan. 2010 Jul;25(4):283-91. doi: 10.1093/heapol/czq001. Epub 2010 Feb 8.
Studies on the relevance of stronger health systems to the success of vertical programmes has focused mainly on developing countries with fragile infrastructures and limited human resources. Research in middle-income, and particularly post-Soviet, settings has been scarce. This article examines the relationships between health system characteristics and the HIV response in Russia, the country which towards the end of the Soviet period had the world's highest ratios of doctors and hospital beds to population and yet struggled to address the growing threat of HIV/AIDS.
The study is based on semi-structured qualitative interviews with policy-makers and senior health care managers in two Russian regions, and a review of published and unpublished sources on health systems and HIV in Russia.
We identified a number of factors associated with the system's failure to address the epidemic. We argue that these factors are not unique to HIV/AIDS. The features of the wider health system within which the HIV response was set up influenced the structure and capacities of the programme, particularly its regulatory and clinical orientation; the discrepancy between formal commitments and implementation; the focus on screening services; and problems with scaling up interventions targeting high-risk groups.
The system-programme interplay is as important in middle-income countries as in poorer settings. An advanced health care infrastructure cannot protect health systems from potential failures in the delivery of vertical programmes. The HIV response cannot be effective, efficient and responsive to the needs of the population if the broader health system does not adhere to the same principles. Strengthening HIV responses in post-Soviet societies will require improvements in their wider health systems, namely advocacy of prevention for high-risk populations, reallocation of resources from curative towards preventive services, building decision-making capacities at the local level, and developing better working environments for health care staff.
研究表明，卫生系统的强弱与垂直规划的成功息息相关，这些研究主要集中在基础设施脆弱、人力资源有限的发展中国家。而对于中等收入国家，尤其是前苏联国家，相关研究则相对较少。本文以俄罗斯为例，检验了卫生系统特征与艾滋病毒应对措施之间的关系。苏联末期，俄罗斯的医生和病床与人口的比例居世界首位，但却难以应对艾滋病毒/艾滋病日益严重的威胁。
本研究基于对俄罗斯两个地区的政策制定者和高级医疗保健管理人员的半结构化定性访谈，以及对俄罗斯卫生系统和艾滋病毒的已发表和未发表资料的审查。
我们确定了一些与该系统未能应对艾滋病流行有关的因素。我们认为，这些因素并非艾滋病所特有。艾滋病毒应对措施所处的更广泛卫生系统的特征影响了方案的结构和能力，特别是其监管和临床定位；正式承诺与实施之间的差距；筛查服务的重点；以及针对高危群体的干预措施扩大化所面临的问题。
系统与方案之间的相互作用在中等收入国家和较贫穷国家同样重要。先进的医疗保健基础设施并不能保护卫生系统免受垂直规划实施潜在失败的影响。如果更广泛的卫生系统不遵循同样的原则，那么艾滋病毒应对措施就不可能是有效、高效和满足人民需求的。要加强在后苏联社会的艾滋病毒应对措施，就需要改善更广泛的卫生系统，即为高危人群倡导预防措施，将资源从治疗转向预防服务，在地方一级建立决策能力，并为医疗保健人员营造更好的工作环境。
