中国医革向何处去？China Health Reform at Crossroad

刘国恩 博士Gordon G. Liu, PhD.

北京大学光华管理学院卫生经济与管理学系 教授，系主任

Email: ggliu@unc.edu; gordon@gsm.pku.edu.cn

Seminar at Peking Union Medical College, Sep 18, 2006

2

演讲内容

1.发生了什么根本问题2.产生问题的本质原因3.科学发展观探讨问题

“看病难 - 看病贵”

当今中国面临的首要社会现象

4

中国 –世界成长最快的转型经济China – the Fastest Transitional Economy

-2

0

2

4

6

8

10

12

14

16

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

China USA World

source: WDI online database, World Bank, source: WDI online database, World Bank, 20052005

5

中国 –世界强大经济体之列China – Leading Economy in the World

11,013

4,361

2,0861,680 1,522 1,417 1,243

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

11,000

USA Japan Germany UK France China Italy

Source: www.worldbank.org

6

80 年代的人均期望寿命LE in 1980: a global over-achiever

India

Indonesia

United States

France

United Kingdom

Brazil

Sri LankaChina

1.5

1.55

1.6

1.65

1.7

1.75

1.8

1.85

1.9

1.95

2

2.5 3 3.5 4 4.5log of GDP per capita, PPP (current international $)

log

of

life

ex

pe

cta

nc

y a

t b

irth

, to

tal

(ye

ars

)

(Eggleston 2004)

7

20 年后的人均期望寿命LE in 2000: median performer

India

IndonesiaChina

Sri Lanka

Russian FederationBrazil

Poland

France

United Kingdom

United States

1.5

1.55

1.6

1.65

1.7

1.75

1.8

1.85

1.9

1.95

2

2.5 3 3.5 4 4.5

log of GDP per capita, PPP (current international $)

log

of

life

exp

ecta

ncy

at

bir

th,

tota

l (y

ears

)

(Eggleston 2004)

8

80 年代初的婴儿死亡率IFM in 1980: a global over-achiever

China

India

Indonesia

Sri Lanka

Brazil

FranceUnited Kingdom

United States

0

0.5

1

1.5

2

2.5

2.5 3 3.5 4 4.5 5log of GDP per capita, PPP (current international $)

log

of m

orta

lity

rate

, inf

ant (

per

1,00

0 liv

e bi

rths

)

(Eggleston 2004)

9

20 年后的婴儿死亡率IMR in 2000: median player

India

IndonesiaChina

Sri Lanka

Brazil

Russian Federation

Poland

FranceUnited Kingdom

United States

0

0.5

1

1.5

2

2.5

2.5 3 3.5 4 4.5 5log of GDP per capita, PPP (current international $)

log

of

mo

rta

lity

ra

te,

infa

nt

(pe

r 1

,00

0 l

ive

bir

ths

)

(Eggleston 2004)

10

期望寿命的相对变化LE: China vs. Rest of the World

50

55

60

65

70

75

80

China Low-Y Middle-Y High-Y World

1980 1998

11

婴儿死亡率的相对变化IMR: China vs. Rest of the World

0

20

40

60

80

100

China Low-Y Middle-Y High-Y World

1980 1998

问题可能出在哪里？Possible Diagnoses

13

卫生总开支并不小Total Spending is SIZABLE

China Total Health Expenditure as % of GDP

2.00

3.00

4.00

5.00

6.00

1978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002Year

%

14

其他国家总开支状况GDP % on Health by Other Nations

0

2

4

6

8

10

12

Source: OECD Health Data 2002

15

政府投入持续下降Government Spending on Health

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002

Year

Government health appropriation Social health expenditure Out-of-pocket health expenditure

16

其他国家政府投入高Health Spending in Other Nations

0

20

40

60

80

100

Aus

tria

Bel

gium

Den

mar

k

Fin

land

Fra

nce

Ger

man

y

Gre

ece

Irel

and

Ital

y

Luxe

mbo

urg

Net

herla

nds

Por

tuga

l

Spa

in

Sw

eden UK

Private

Public

17

中央与地方财政投入

3%

97%

中央 地方

18

共识一：国家健康投入太少

需方筹资问题 (Financing) 降低基本医疗服务的可及性，尤其是贫困人群 负面改变个人就医行为，加大“抗、拖、重”程

度

供方服务问题 (Organization) 质量降低？ 垄断价格？ (P>>MC)

19

有限资源的不公平分配Inequitable Financing Scheme

InsuredUninsured

Insured

Uninsured

Rural

Urban

20

城乡卫生服务使用的差距Severely Under-served Care for the Rural

0

100

200

300

400

500

199019911992199319941995 1996199719981999200020012002

Urban Rural

WHO report (2000):

188th of 191 WHO member nations in

terms of equity

MOH Report

40-60% of Rural Pop did not seek care due to financial

barrier; leading to over 60% of deaths died home without care

21

边际报酬递减律

365 days365 days

HHminmin

Health

y d

ays

Health

y d

ays

Health Stock Health Stock InvestmentInvestment

Grossman Health Production Function Grossman Health Production Function (1972)(1972)

22

共识二：资源配置低效

高端医院 “吃不完” – 价格飞涨 低端机构 “吃不饱” – 闲置倒闭

加剧了看病难 - 看病贵问题

23

低效的服务支付模式Inefficient Reimbursement Model

Fee-for-Service Model

Pre-reform Era: FFS was NOT a significant issue due to lack of incentives for service providers

Post-reform Era: FFS serves as a major driving force for the over-use of care or induced demand in response to the strong economic incentives

24

扭曲的市场竞争条件Distorted Market Competitive Conditions

Public Hospital Providers Government subsidy for

wages Tax free advantages Service price regulation

Private Hospital Providers No government subsidies High tax rates Other unfair market

barriers

Difficult careExpensive care

看病难看病贵

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共识三：缺乏竞争激励机制

国营机构“一统天下”，缺乏有效竞争和激励机制，使得垄断价格从可能成为现实；

而卫生服务市场的信息不对称： 垄断作业与寻租价格程度更为严重

26

公 - 民营医院医疗费用对比

数据来源：浙江省温州市卫生经济学会 2004

科学发展观与战略选择

发展战略 I - 健康投资Controlling for other factors, pure health effect on GDP growth is about 1.4% for every 13 years in life expectancy (Barro and Sala-i-Martin 1995)WHO study (2001): each 10% improvement in LE leads to 0.3-0.4% in economic growth, controlling for other conditions

Macro studies: Bloom and Sachs 1998; Bloom and Canning 2000; Bhargava et al. 2001; Bloom, Canning, and Sevilla 2001); Bhargava, Jamison, Lau, and Murray, 2001

Micro studies: Strauss and Thomas 1998; Glick and Sahn 1998; Schultz

1999, 2001, 2002;

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健康投资 = 人力资本基石

Demand for Health (Grossman 1972) offers more specific insights on the dual roles of health

consumption purpose

investment purpose

Becker G., Econ J., 1965, 75(299): 493-517; Grossman M., JPE, 1972, 80(2): 223-255.

Human Capital Theory (Becker 1965)

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健康的高收入弹性

Income-health elasticity 1.6 (health) 1.6 (education) 0.7 (house) 0.3 (cloth) 0.2 (food) 1.1 (others)

57% 14%

16%

2% 1%

10%

12% 4%

14%

23% 12%37%

0%

20%

40%

60%

80%

100%

1875 1995

UK case: 20-30% of the income growth (1780-1979) attributable to health and nutrition improvement)

31

健康与经济增长 – 描述统计

32

基于中国的证据

33

健康投资的收入回报

Urban

Urban

Rural

Rural

Rural

Urban0

50

100

150

200

250

Fair Good Excellent

1989-1995 Data

34

健康投资的收入回报

Men

Men

Women

Women

Women

Men20

70

120

170

220

270

320

Fair Good Excellent

1989-1995 Data

国家发展战略：全民健保 经济理论支持

符合政府干预弥补市场失灵对公共卫生和贫穷人群的照顾；边际效益理论

政治伦理价值 “以人为本”的治国方针；实现中国“人人健康”目标的承

诺 国际实践：泰国范例 美国《独立宣言》： life, liberty, and pursuit of

happiness

机构良性循环 有效初级卫生需求增加；促进初级医疗机构和人员发展的良

性循环；有利区域卫生规划。

发展战略 II – 全民健保

36

全民健保筹资可行性

02000400060008000

100001200014000160001800020000

亿元

中央财政收入 地方财政收入

37

财政盈余 /赤字的变化

-8000. 00

-6000. 00

-4000. 00

-2000. 00

0. 00

2000. 00

4000. 00

6000. 00

1980

1985

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002亿元 中央

地方

38

有效筹资 - 开支模式

中央财政 地方财政单位补助个人负担

初级保健基本医疗

财政政策专业支持 差异支付差异支付

39

发展战略 III – 管理竞争 政府垄断 – 低效、寻租、腐败的温床

政府的“三只手”功能：无为；扶持；掠夺

管理竞争模式 (Managed Competition) 市场竞争 – 效率目标 （服务组织） 政府干预 – 公平目标 （服务筹资）

激励相容的合同 Doctors hold a key of success Contracting with compatible incentives!!!!

Incentive Matters

“If health-care providers are reimbursedon the basis of how healthy their patients are,

then they will have enormous incentives to do all the right things”

Larry Summers (2004) – Larry Summers (2004) – 哈佛大学哈佛大学前任校长前任校长