全民健康覆盖与卫生部门间行动:《疾病控制优先领域》第三版的主要信息。
Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition.
机构信息
University of California, San Francisco, San Francisco, CA, USA.
University of Washington, Seattle, WA, USA.
出版信息
Lancet. 2018 Mar 17;391(10125):1108-1120. doi: 10.1016/S0140-6736(17)32906-9. Epub 2017 Nov 25.
The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.
世界银行将于 2015 年至 2018 年出版《疾病控制优先事项》第三版的九卷本。第 9 卷《改善健康与减少贫困》概括了所有九卷本的主要信息,并包含了跨领域的分析。本述评借鉴了所有九卷本的内容来传达结论。DCP3 的分析围绕着在九卷本中制定的 21 个基本方案展开。每个基本方案都涉及到一个主要专业领域的关注问题(例如儿童健康或外科),并包含了一系列跨部门政策和卫生部门干预措施。总共确定了 71 项跨部门预防政策,其中 29 项是优先考虑早期实施的。卫生部门内的干预措施被分为五个平台(以人群为基础、社区一级、保健中心、一级医院和转诊医院)。DCP3 定义了一个基本的全民健康覆盖(UHC)模式概念,其中包含 218 项干预措施,为国家特定的优先事项分析提供了一个起点。假设到 2030 年实现稳定实施,中低收入国家的基本 UHC 每年将减少约 420 万例过早死亡。估计的总成本是相当大的:低收入国家约占(当前)国民总收入(GNI)的 9.1%,中低收入国家占 GNI 的 5.2%。为持续干预慢性病提供资金占估计增量成本的一半左右。对于中低收入国家,实施基本 UHC 带来的死亡率降低,只能达到可持续发展目标所呼吁的减少非传染性疾病死亡率的一半。要实现全面目标,需要增加投资或持续开展跨部门行动,财政部采取行动对吸烟和污染排放征税,并减少或取消(通常是大量的)对化石燃料的补贴,这似乎至关重要。DCP3 旨在成为国家层面分析的一个模式起点,但各国具体的成本结构、流行病学需求和国家优先事项通常会导致各国之间和本述评中的模式之间对 UHC 的定义有所不同。DCP3 特别重要,因为 UHC 的实现越来越依赖于更多的国内资金,而全球卫生发展援助则更多地侧重于全球公益物。除了评估对死亡率的影响外,DCP3 还研究了 UHC 的结果,这些结果没有包含在残疾调整生命年指标和相关成本效益分析中。其他目标包括财务保护(通过让人们远离医院而不是通过支付他们的医院账单来保护他们,上游可能提供更好的保护)、避免死产、姑息治疗、避孕和儿童身体和智力发育。受孕后最初的 1000 天对儿童发育非常重要,但接下来的 7000 天同样重要,而且往往被忽视。
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