Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
Health Policy Plan. 2012 Oct;27 Suppl 4:iv44-53. doi: 10.1093/heapol/czs085.
Although health interventions start with good intentions to develop services for disadvantaged populations, they often distort the health market, making the delivery or financing of services difficult once the intervention is over: a condition called the 'Develop-Distort Dilemma' (DDD). In this paper, we describe how to examine whether a proposed intervention may develop or distort the health market. Our goal is to produce a tool that facilitates meaningful and systematic dialogue for practitioners and researchers to ensure that well-intentioned health interventions lead to productive health systems while reducing the undesirable distortions of such efforts. We apply the DDD tool to plan for development rather than distortions in health markets, using intervention research being conducted under the Future Health Systems consortium in Bangladesh, China and Uganda. Through a review of research proposals and interviews with principal investigators, we use the DDD tool to systematically understand how a project fits within the broader health market system, and to identify gaps in planning for sustainability. We found that while current stakeholders and funding sources for activities were easily identified, future ones were not. The implication is that the projects could raise community expectations that future services will be available and paid for, despite this actually being uncertain. Each project addressed the 'rules' of the health market system differently. The China research assesses changes in the formal financing rules, whereas Bangladesh and Uganda's projects involve influencing community level providers, where informal rules are more important. In each case, we recognize the importance of building trust between providers, communities and government officials. Each project could both develop and distort local health markets. Anyone intervening in the health market must recognize the main market perturbations, whether positive or negative, and manage them so as to maximize the benefits to the health system and population health.
尽管卫生干预措施最初是出于为弱势群体提供服务的良好意图，但它们常常会扭曲卫生市场，一旦干预措施结束，服务的提供或融资就会变得困难：这种情况被称为“发展-扭曲困境”（DDD）。本文描述了如何检查拟议的干预措施是否可能发展或扭曲卫生市场。我们的目标是开发一种工具，为从业者和研究人员提供有意义和系统的对话，以确保有良好意图的卫生干预措施能够促进富有成效的卫生系统，同时减少这些努力带来的不良扭曲。我们将 DDD 工具应用于计划中的发展，而不是卫生市场的扭曲，使用正在孟加拉国、中国和乌干达进行的未来卫生系统联盟中的干预研究。通过对研究提案的审查和对主要研究者的访谈，我们使用 DDD 工具系统地了解一个项目如何适应更广泛的卫生市场系统，并确定可持续性规划中的差距。我们发现，虽然很容易确定当前活动的利益相关者和资金来源，但未来的利益相关者却不容易确定。这意味着项目可能会提高社区对未来服务将可用和付费的期望，尽管这实际上是不确定的。每个项目都以不同的方式解决了卫生市场系统的“规则”。中国的研究评估了正式融资规则的变化，而孟加拉国和乌干达的项目则涉及影响社区层面的提供者，在这种情况下，非正式规则更为重要。在每种情况下，我们都认识到在提供者、社区和政府官员之间建立信任的重要性。每个项目都可能同时发展和扭曲当地的卫生市场。任何干预卫生市场的人都必须认识到主要的市场波动，无论是积极的还是消极的，并加以管理，以最大限度地提高卫生系统和人口健康的利益。
