中国卫生筹资转型的主要特征与历史沿革

Main characteristics and historical evolution of China’s health financing transition

目的:了解中国卫生筹资转型的主要特征及历史沿革。方法:数据来源于全球卫生支出数据库(Global Health Expenditure Database,GHED)、《中国卫生健康统计年鉴》、《全国卫生健康财务年报》、《中国卫生总费用研究报告》等。采用描述性统计和文献研究法进行分析。结果:21世纪以来,全球多数国家出现了卫生筹资转型现象,表现为卫生筹资规模扩大和公共筹资责任强化。中国的卫生筹资转型特征十分鲜明:一是卫生筹资规模扩大的速度更快,2000—2019年人均卫生总费用按可比价格水平增长了816.6%,明显快于全球其他国家的平均增长速度(102.1%);二是公共筹资责任强化的力度更大,2000—2019年个人现金卫生支出占卫生总费用的比例下降了30.6个百分点,降幅明显大于全球其他国家的平均水平(5.6个百分点);三是公共筹资中政府卫生支出的流向发生了重要转变,“补需方”占比逐渐提高,并于2011年超过“补供方”,同时,在“补供方”内部“补医院”占比持续增加,明显高于“补基层”和“补公卫”。据此可将中国卫生筹资转型扩展为规模维度、结构维度和流向维度三个维度。运用分析框架,将中国卫生筹资转型大致分为计划经济时期、经济转型时期、“后非典”时期和“新医改”以来4个阶段,并对每个阶段的主要特点和演变逻辑进行了分析。结论:应从系统结构功能层面提高卫生筹资体系的纵向“嵌入性”和横向“互补性”;更加突出卫生筹资转型对维护隐性价值和防范公共风险的作用,完善价值与风险的双向权衡机制;统筹兼顾卫生筹资转型所涉及的卫生健康伦理原则,优化政府实际治理模式下的预算决策机制;高度重视现代医学发展的全局性和深层次影响,探索中国卫生筹资转型的长期战略和路径选择。

Objective:To comprehend the main characteristics and historical evolution of health financing transition in China.Methods:Data were collected from various sources,including the Global Health Expenditure Database(GHED),China Health Statistics Yearbook,National Health Finance Annual Report,China’s Total Health Expenditure Research Report,et al.Descriptive statistics and literature study was conducted.Results:Since the beginning of the 21st century,most countries in the world had witnessed a transition of health financing,characterized by the expansion of health financing scale and the strengthening of public financing responsibility.Notably,China’s health financing transition exhibited distinctive features.Firstly,there had been a more rapid expansion in health financing scale compared with global averages.Between 2000 and 2019,total health expenditure per capita experienced a remarkable increase of 816.6%at comparable prices,significantly surpassing average growth rates observed among other countries worldwide(102.1%).Secondly,greater efforts had been made to strengthen the responsibilities of public financing.From 2000 to 2019,there was a substantial decrease of 30.6 percentage points in the proportion of out-of-pocket health expenditure as a share of total health expenditure.This decline was significantly larger than the average reduction observed among other countries worldwide(5.6 percentage points).Thirdly,there had been a significant shift in government health expenditure allocation patterns,with an increased emphasis on“demand-side subsidies”surpassing“supply-side subsidies”.Within the realm of“supply-side subsidies”,funding directed towards hospitals had notably increased and surpassed that allocated to primary healthcare institutions and public health institutions.Based on these distinctive characteristics,this paper expanded China’s health financing transition into three dimensions:Scale dimension,structure dimension and flow dimension.Using a comprehensive analytical framework,the history of China’s health financing transition was roughly divided into four stages:The planned economy stage,the economic transition stage,the post-SARS stage and the new health system reform stage.The main features and evolutionary logic associated with each stage were analyzed.Conclusion:Above all,the health financing system should be enhanced in terms of vertical“embeddedness”and horizontal“complementarity”.Moreover,the significance of health financing transition in preserving hidden value and mitigating public risk should be emphasized,and there is a need for an improved two-way trade-off mechanism that balances value and risk.Additionally,the ethical principles associated with health financing transition should be considered comprehensively,while optimizing budget decision-making within the government’s actual governance model.Lastly,it is crucial to recognize the overall and profound impact of modern medicine development and explore long-term strategies and pathways for health financing transition in China.