七个发达国家卫生系统的领导与治理

Leadership and governance in seven developed health systems

本文运用结构式调查方法,探讨了澳大利亚、英国、德国、荷兰、挪威、瑞典和瑞士七个发达国家卫生系统的领导和治理情况。领导与治理模式包含三项基本职能:优先顺序设置、绩效监管和问责制。各国卫生系统的领导和治理方法存在着显著差异,零散并略显随意。虽然各国在卫生系统的总体目标上达成了共识,但设置优先顺序的途径各不相同。成本效益分析作为设置卫生系统运行优先顺序的一个主要方法被各国加以广泛运用,但并未发挥核心作用。各国虽然处于不同的发展阶段,但绩效监管却能广泛吸收有益意见。问责制特别是在最优方法的不确定性方面,各国之间的差异最大。大多数情况下,市场机制、选举程序、直接经济激励以及专业监督与控制等几种不同问责机制的组合可能更为合适。而且这些机制应与优先顺序设置和绩效监管协调一致。

This paper uses a structured survey to explore leadership and governance arrangements in seven developed health systems：Australia, England,Germany,the Netherlands,Norway,Sweden and Switzerland. It presents a cybernetic model of leadership and governance comprising three fundamental functions：priority setting,performance monitoring and accountability arrangements. Approaches to leadership and governance vary substantially,and have to date been developed piecemeal and somewhat arbitrarily. Although there seems to be reasonable consensus on broad goals of the health system there is variation in approaches to setting priorities. Cost-effectiveness analysis is in widespread use as a basis for operational priority setting, but rarely plays a central role. Performance monitoring may be the domain where there is most convergence of thinking,although countries are at different stages of development. The third domain of accountability is where the greatest variation occurs,and where there is greatest uncertainty about the optimal approach. We conclude that a judicious mix of accountability mechanisms is likely to be appropriate in most settings,including market mechanisms, electoral processes,direct financial incentives,and professional oversight and control. The mechanisms should be aligned with the priority setting and monitoring processes.