Institute of Tropical Medicine, Antwerp, Belgium.
Health Policy Plan. 2011 Jul;26 Suppl 1:i30-44. doi: 10.1093/heapol/czr026.
In spite of all efforts to build national health services, health systems of many low-income countries are today highly pluralistic. Households use a vast range of public and private health care providers, many of whom are not controlled by national health authorities. Experts have called on Ministries of Health to re-establish themselves as stewards of the entire health system. Modern stewardship will require national and decentralized health authorities to have an overall view of their pluralistic health system, especially of the components outside the public sector. Little guidance has been provided so far on how to develop such a view. In this paper, we explore whether household surveys could be a source of information. The study builds on secondary data analysis of a household survey carried out in three health districts in rural Cambodia and of two national surveys. Cambodia is indeed an interesting case, as massive efforts by donors in favour of the public sector go hand in hand with a dominant role of the private sector in the provision of health care services. The study confirms that the health care sector in Cambodia is now highly pluralistic, and that the great majority of health seeking behaviour takes place outside the public health system. Our analysis of the survey also shows that the disaffection of the population with public health facilities varies across places, socio-economic groups and health problems. We illustrate how such knowledge could allow stewards to better identify challenges for existing or future health policies. We argue that a whole research programme on the composition of pluralistic health systems still needs to be developed. We identify some challenges and opportunities.
尽管各国努力建立国家卫生服务体系，但许多低收入国家的卫生系统如今呈现高度多元化的特点。家庭会利用广泛的公共和私人医疗服务提供者，其中许多提供者不受国家卫生当局的控制。专家呼吁各国卫生部重新将自己定位为整个卫生系统的管理者。现代管理将要求国家和地方卫生当局全面了解其多元化的卫生系统，特别是了解公共部门以外的组成部分。到目前为止，几乎没有提供如何发展这种观点的指导。本文探讨了家庭调查是否可以成为信息来源。该研究基于对柬埔寨三个农村地区家庭调查以及两项全国性调查的二次数据分析。柬埔寨确实是一个有趣的案例，因为捐赠者为支持公共部门做出了巨大努力，同时私营部门在提供医疗服务方面也发挥着主导作用。研究证实，柬埔寨的医疗保健部门现在呈现出高度多元化的特点，绝大多数寻求医疗的行为都发生在公共卫生系统之外。我们对调查的分析还表明，民众对公共卫生设施的不满程度因地点、社会经济群体和健康问题而异。我们举例说明了这种知识如何使管理者能够更好地确定现有或未来卫生政策面临的挑战。我们认为，仍需要制定一个关于多元化卫生系统构成的整个研究计划。我们确定了一些挑战和机遇。
