Carr-Hill R A
Department of International and Comparative Education, University of London, England.
Soc Sci Med. 1994 Nov;39(9):1189-201. doi: 10.1016/0277-9536(94)90351-4.
The purpose of the paper is to reflect on the recent health care reforms in both developed and developing countries, in the light of the evidence that has accumulated over the last few years about the efficiency and equity of different fiscal and organisational arrangements. The scene is set by a brief review of the definitions of efficiency and equity and of the confusions that often arise; and of the problems of making assessments in practice with real data. The evidence about effectiveness, efficiency and equity at the macro level are reviewed: among OECD countries, there is little evidence that variations in the levels and composition of health service expenditure actually affect levels of health; equity in financing and delivery appears to mirror equity in other sectors in the same countries; about the only solid--although rather limp--conclusion which is transferable is that costs can be contained best via global budgeting. The range of reforms in the North is sketched: despite calls to give people 'freedom' to opt out, public finances continues to be preferred among OECD countries; and the evidence that health care markets can actually function is 'weak'. Whilst geographical redistribution of finance has proved to be possible, inequalities in health remain in most countries. But the overwhelming impression is that the quality of the data base for many of these studies is appalling, and the analytice techniques used are simplistic. The move to introduce user charges in the South is discussed. It seems unlikely that they will raise a significant fraction of overall revenue; exemptions intended for the poor do not always work; and other trends are likely to exacerbate the patchy coverage of health care systems in the South. The final section reflects on the pressures for increased accountability. The emphasis on consumerism in the North has led to an increasing number of poorly designed 'patient satisfaction' surveys; in the South, there has been an increasing rhetoric on community participation, but little sign of actual devolution of control. The flavour of the decade is 'outcome measurement' which has been promoted feverish but with little rigour. We must also be concerned that this emphasis will, once again, be hijacked by the most articulate.
本文旨在根据过去几年积累的有关不同财政和组织安排的效率与公平性的证据，对发达国家和发展中国家近期的医疗改革进行反思。文章首先简要回顾了效率与公平的定义以及常常出现的混淆之处，还回顾了在实际中运用真实数据进行评估时所存在的问题，以此作为铺垫。接着审视了宏观层面有关有效性、效率和公平性的证据：在经合组织国家中，几乎没有证据表明医疗服务支出水平及构成的差异实际上会影响健康水平；融资和服务提供方面的公平性似乎反映了同一国家其他部门的公平性；唯一可借鉴的可靠（尽管有些无力）结论是，通过全球预算编制能够最好地控制成本。文章概述了北方国家的改革范围：尽管有人呼吁给予人们选择退出的“自由”，但在经合组织国家中，公共财政仍是首选；而且医疗保健市场实际能够发挥作用的证据“薄弱”。虽然已证明资金的地域再分配是可行的，但大多数国家的健康不平等现象依然存在。不过，给人留下的总体印象是，许多此类研究的数据库质量糟糕，所使用的分析技术也过于简单。文中讨论了南方国家引入使用者付费的举措。使用者付费似乎不太可能筹集到占总收入很大比例的资金；旨在帮助穷人的豁免措施并不总是有效；而且其他趋势可能会加剧南方国家医疗保健系统覆盖范围的不均衡。最后一部分反思了加强问责制所面临的压力。北方国家对消费主义的强调导致设计糟糕的“患者满意度”调查越来越多；在南方国家，有关社区参与的言辞日益增多，但几乎没有实际控制权下放的迹象。这十年的特点是“结果衡量”，它虽被大力鼓吹，但缺乏严谨性。我们还必须担心，这种强调会再次被最能说会道的人利用。
