【摘要】：研究背景與目的我國正處于醫(yī)療衛(wèi)生體制改革深水期,在衛(wèi)生系統(tǒng)的調(diào)整和升級過程中迫切需要可靠、穩(wěn)定的數(shù)據(jù)支持,反映衛(wèi)生系統(tǒng)前期改革效果的現(xiàn)狀、調(diào)整與把握醫(yī)藥衛(wèi)生體制改革方向。而衛(wèi)生總費(fèi)用作為宏觀核算體系,可以全面系統(tǒng)地反映衛(wèi)生服務(wù)經(jīng)濟(jì)運(yùn)行過程,揭示衛(wèi)生領(lǐng)域經(jīng)濟(jì)活動規(guī)律,為制定政策、監(jiān)測和評價政策執(zhí)行情況提供信息。如今,衛(wèi)生總費(fèi)用核算已逐步被列為計財部門的經(jīng)常性工作,其分析研究正朝著"發(fā)揮更有效的政策咨詢作用"方向前進(jìn)。SHA2011(System of Health Accounts 2011)是最先進(jìn)的衛(wèi)生總費(fèi)用核算體系,可以進(jìn)行任意維度的交叉平衡核算與分析,全方位反映衛(wèi)生資金流動過程。伴隨SHA2011在我國"亞國家級(省/市)"的核算推廣,SHA2011即將產(chǎn)出的大量衛(wèi)生費(fèi)用數(shù)據(jù)可以有力地支持核算地的政策應(yīng)用研究。然而,現(xiàn)階段基于衛(wèi)生費(fèi)用政策應(yīng)用研究仍存在以下問題:1、衛(wèi)生費(fèi)用的分析研究多伴隨核算研究而展開,往往局限于對數(shù)據(jù)結(jié)果的描述性分析,缺乏評價性分析;2、后置于數(shù)據(jù)結(jié)果的衛(wèi)生費(fèi)用分析研究往往缺乏主動的政策應(yīng)用研究設(shè)計,容易忽略重要的衛(wèi)生政策關(guān)注點(diǎn);3、我國尚未出臺"SHA2011衛(wèi)生費(fèi)用的分析指南","亞國家級"在運(yùn)用SHA2011數(shù)據(jù)進(jìn)行衛(wèi)生政策的應(yīng)用轉(zhuǎn)化中存在困難。鑒于此情景,為了更好地應(yīng)用SHA2011為政策研究服務(wù),本研究擬建立基于政策需求的SHA2011政策分析框架,開發(fā)SHA2011指標(biāo)并拓展其政策應(yīng)用意義,理清SHA2011指標(biāo)研究空白點(diǎn)與下一步研究方向,指導(dǎo)SHA2011衛(wèi)生費(fèi)用發(fā)揮更有效的政策咨詢作用。研究方法與結(jié)果本研究依托于北京市2014年衛(wèi)生總費(fèi)用研究課題,運(yùn)用文獻(xiàn)研究法和歸納演繹等邏輯思維方法,借鑒政策研究指標(biāo)體系的構(gòu)建方法,主要研究結(jié)果如下:1、構(gòu)建了 SHA2011政策分析概念框架本文首先從衛(wèi)生政策評估分析的基本理論與方法入手,借鑒"衛(wèi)生系統(tǒng)宏觀模型"的研究思路,結(jié)合"系統(tǒng)論"和"結(jié)構(gòu)-過程-結(jié)果"理論,確定基于SHA2011的"衛(wèi)生籌資系統(tǒng)"的研究范圍,和基于"結(jié)構(gòu)-過程-結(jié)果"的SHA2011政策分析框架模型基礎(chǔ);通過研究"結(jié)構(gòu)-過程-結(jié)果"理論三個維度的內(nèi)涵與演變,合理調(diào)整適用于SHA2011的"結(jié)構(gòu)-過程"框架要素和"結(jié)果"的"評價準(zhǔn)則",創(chuàng)造性地構(gòu)建了 SHA2011政策分析概念框架模型。其次,本研究借鑒指標(biāo)屬性分組法"范圍法"與"問題法"的思路,分別從衛(wèi)生籌資系統(tǒng)"全局"和"局部(具體)"衛(wèi)生政策的視角對以上框架模型進(jìn)行拓展,構(gòu)建了基于衛(wèi)生籌資系統(tǒng)和基于衛(wèi)生政策子系統(tǒng)的SHA2011政策分析概念框架。2、構(gòu)建了 SHA2011政策分析框架指標(biāo)體系本研究借鑒指標(biāo)體系的構(gòu)建方法,主要研究過程分兩步:第一步,運(yùn)用"文獻(xiàn)研究法、綜合法、交叉法"開發(fā)SHA2011指標(biāo)群。通過對"指標(biāo)別"和傳統(tǒng)衛(wèi)生總費(fèi)用常見指標(biāo)的系統(tǒng)總結(jié),歸納衛(wèi)生總費(fèi)用"指標(biāo)別"的共性特點(diǎn),以此為依據(jù)拓展開發(fā)SHA2011指標(biāo)(群),推演探索其政策應(yīng)用意義。該步驟是對SHA2011指標(biāo)(群)的系統(tǒng)開發(fā)與總結(jié)。第二步,構(gòu)建SHA2011政策分析框架指標(biāo)體系。首先運(yùn)用"范圍法",根據(jù)SHA2011的主要研究內(nèi)容(籌資功能)將SHA2011指標(biāo)群與本研究的"概念框架"對接,從衛(wèi)生籌資系統(tǒng)"全局"的視角構(gòu)建了 SHA2011的政策分析框架指標(biāo)體系。該框架將SHA2011衛(wèi)生費(fèi)用變化視為各類衛(wèi)生政策交互作用的共同結(jié)果,是通過SHA2011指標(biāo)體系評價"整體"衛(wèi)生政策(群)的實施效果。該框架構(gòu)建了對"整體"衛(wèi)生籌資政策的SHA2011分析評價方法。其次,運(yùn)用"指標(biāo)屬性分組法-問題法和目標(biāo)法",依據(jù)劃分的六個政策問題子系統(tǒng)提煉"政策目標(biāo)",再以"政策目標(biāo)"分別匹配本研究概念框架的"結(jié)果"和"結(jié)構(gòu)、過程"(SHA2011)指標(biāo),構(gòu)建基于政策問題子系統(tǒng)的SHA2011政策分析框架指標(biāo)體系。該框架將"政策目標(biāo)"對接具體的SHA2011指標(biāo),更有針對性地解讀SHA2011指標(biāo)的政策應(yīng)用意義。一方面,構(gòu)建(驗證)本研究中部分SHA2011指標(biāo)群的政策應(yīng)用情景;另一方面,根據(jù)政策目標(biāo)需求進(jìn)一步補(bǔ)充SHA2011指標(biāo)群,拓展政策應(yīng)用意義。該框架構(gòu)建了對"局部(具體)"衛(wèi)生籌資政策的SHA2011分析評價方法。3、研究SHA2011指標(biāo)體系現(xiàn)狀首先,匯總本研究中所涉及的全部SHA2011指標(biāo)群,展示其在SHA2011政策分析概念框架中的應(yīng)用,總結(jié)我國SHA2011文獻(xiàn)研究中"尚未應(yīng)用分析"的指標(biāo)(群);其次,對北京市SHA2011已有核算數(shù)據(jù)支持系統(tǒng)的情況進(jìn)行指標(biāo)群的現(xiàn)況總結(jié):一方面,總結(jié)已有核算數(shù)據(jù)支持的SHA2011指標(biāo)(群),列明其數(shù)據(jù)表來源;另一方面,對尚無核算數(shù)據(jù)支持的指標(biāo)群,列明其尚需補(bǔ)充的數(shù)據(jù)。研究結(jié)論與意義1、本研究創(chuàng)造性地構(gòu)建了 SHA2011政策分析概念框架,為SHA2011的評價研究提供新思路:1)本研究以衛(wèi)生籌資理論和福利經(jīng)濟(jì)學(xué)理論為基礎(chǔ),首先論證了衛(wèi)生籌資目標(biāo)在籌資功能中的體現(xiàn),其次論證了 SHA2011與衛(wèi)生籌資的緊密聯(lián)系,得出以下結(jié)論:"SHA2011與衛(wèi)生籌資系統(tǒng)展現(xiàn)了相似的衛(wèi)生資金流動過程,SHA2011可以體現(xiàn)衛(wèi)生籌資的全部功能與目標(biāo);衛(wèi)生籌資目標(biāo)(充足、可持續(xù)、公平、效率)可作為SHA2011衛(wèi)生費(fèi)用的評價準(zhǔn)則"。2)本研究創(chuàng)造性地調(diào)整、構(gòu)建了適用于SHA2011的"結(jié)構(gòu)-過程-結(jié)果"分析框架。首先,通過對框架要素的調(diào)整(將傳統(tǒng)"結(jié)構(gòu)"概念中的"投入要素"部分歸入"過程"中),形成適用于SHA2011的"狹義結(jié)構(gòu)"指標(biāo)和"廣義過程"指標(biāo),分別以SHA2011資本形成費(fèi)用和經(jīng)常性衛(wèi)生費(fèi)用代表。其次,通過對"結(jié)果"指標(biāo)的討論,選定以衛(wèi)生籌資目標(biāo)作為"系統(tǒng)結(jié)果"指標(biāo),完成SHA2011政策分析概念框架的構(gòu)建。3)本研究探討了 SHA2011框架中"結(jié)構(gòu)-過程-結(jié)果"的辯證關(guān)系。提出以下觀點(diǎn):SHA2011 "結(jié)構(gòu)"與"過程"不僅可以單獨(dú)反映"結(jié)果",二者還相輔相成,且在同向變化時更易取得最優(yōu)"結(jié)果"。具體如下:改變"結(jié)構(gòu)"的目的是引起"過程"的改變;"過程"的改變又可以反向促進(jìn)"結(jié)構(gòu)"的改變;"結(jié)構(gòu)"與"過程"同向改變時更易取得最優(yōu)"結(jié)果"。SHA2011政策分析概念框架的提出,不僅為SHA2011的分析與政策應(yīng)用研究提供了"評價準(zhǔn)則"和分析思路,還提出在分析研究中應(yīng)將SHA2011相互獨(dú)立的資本形成費(fèi)用與經(jīng)常性衛(wèi)生費(fèi)用聯(lián)合分析,在政策應(yīng)用研究中關(guān)注二者聯(lián)系、以"聯(lián)合"分析取代"割裂"分析的觀點(diǎn),為SHA2011的評價與分析研究提供新思路。2、本研究拓展開發(fā)了 SHA2011指標(biāo)(群),推演探索了其政策應(yīng)用意義,為SHA2011數(shù)據(jù)的政策應(yīng)用轉(zhuǎn)化提供參考。1)按"指標(biāo)別"歸納傳統(tǒng)衛(wèi)生總費(fèi)用指標(biāo)的共性和特點(diǎn),拓展、開發(fā)SHA2011指標(biāo)(群)及其政策應(yīng)用意義。一方面,研究SHA2011尚未開展核算的擴(kuò)展維度分類口徑,構(gòu)建SHA2011指標(biāo)(群)及其可能的政策應(yīng)用情景;另一方面,掌握SHA2011現(xiàn)有數(shù)據(jù)及核算過程,拓展分析角度,創(chuàng)新SHA2011指標(biāo)及其應(yīng)用意義。2)根據(jù)"政策問題子系統(tǒng)"中總結(jié)的"政策目標(biāo)",以及"政策目標(biāo)"與具體SHA2011指標(biāo)的對接,構(gòu)建SHA2011指標(biāo)群的政策應(yīng)用情景,驗證指標(biāo)的政策應(yīng)用意義,并根據(jù)政策需求進(jìn)一步擴(kuò)充SHA2011指標(biāo)。3、本研究基于政策需求系統(tǒng)構(gòu)建了 SHA2011政策分析框架的指標(biāo)體系,為政策評估分析服務(wù)。1)從衛(wèi)生籌資系統(tǒng)"全局"的視角構(gòu)建了涵蓋SHA2011主要研究內(nèi)容的政策分析框架指標(biāo)體系。該框架構(gòu)建了 SHA2011對"整體"衛(wèi)生籌資系統(tǒng)政策的分析評價方法。2)從"局部"視角構(gòu)建了基于"政策問題子系統(tǒng)"的SHA2011政策分析框架指標(biāo)體系。該框架構(gòu)建了 SHA2011對"局部(具體)"衛(wèi)生籌資政策的分析評價方法。4、本研究系統(tǒng)總結(jié)了 SHA2011指標(biāo)體系的研究現(xiàn)狀,理清SHA2011現(xiàn)階段研究的空白點(diǎn),指出目前已分析應(yīng)用的指標(biāo)和尚未分析應(yīng)用的指標(biāo),為北京市下一步的研究方向提供參考。其中,"尚未分析應(yīng)用的指標(biāo)"又包括"尚無"核算數(shù)據(jù)支持的指標(biāo)和"已有"核算數(shù)據(jù)支持的指標(biāo)。一方面,對尚無核算方法和數(shù)據(jù)支持的指標(biāo)群,本研究探索其政策應(yīng)用意義,為SHA2011下一步的核算與分析研究提供方向性指導(dǎo);另一方面,對已有核算數(shù)據(jù)系統(tǒng)支持的指標(biāo)群,本研究根據(jù)可得數(shù)據(jù)拓展了分析角度,開發(fā)其政策應(yīng)用意義,為SHA2011的深度分析研究提供參考。
[Abstract]:Background and Objectives China is in the deep-water period of medical and health system reform. Reliable and stable data support is urgently needed in the process of adjustment and upgrading of the health system, reflecting the status quo of pre-reform effect of the health system, and adjusting and grasping the direction of medical and health system reform. It reflects the economic operation process of health services systematically, reveals the law of economic activities in the health field, and provides information for formulating policies, monitoring and evaluating the implementation of policies. SHA2011 (System of Health Accounts 2011) is the most advanced system of total health expenditure accounting, which can carry out cross-balanced accounting and analysis of any dimension and reflect the process of health fund flow in an all-round way. However, there are still some problems in the application of health expenditure policy: 1. The analysis of health expenditure is usually carried out with accounting research, which is limited to the descriptive analysis of data results and lacks of evaluation analysis; 2. The analysis of health expenditure based on data results is placed in the past. In the past, there was a lack of active policy application design, which tended to overlook important health policy concerns. 3. China has not yet published the "SHA2011 health expenditure analysis guide" and "sub-national" in the use of SHA2011 data in the application of health policy transformation difficulties. The purpose of this study is to establish a policy analysis framework for SHA2011 based on policy needs, develop SHA2011 indicators and expand its policy application significance, clarify the research gaps and future research directions of SHA2011 indicators, and guide SHA2011 health expenditure to play a more effective policy advisory role. The main research results are as follows: 1. The conceptual framework of SHA2011 policy analysis is constructed. Firstly, the basic theories and methods of health policy evaluation and analysis are introduced, and the research of "macro model of health system" is used for reference. Based on the theory of "system theory" and "structure-process-result", the research scope of "health financing system" based on SHA 2011 and the model foundation of SHA 2011 policy analysis framework based on "structure-process-result" are determined. The conceptual framework model of SHA2011 policy analysis is constructed creatively by the evaluation criteria of process "framework elements" and "outcome". Secondly, this study extends and constructs the above framework model from the perspective of "overall" and "partial (specific) health policy" of health financing system, drawing on the ideas of "scope" and "problem" of index attribute grouping method. The conceptual framework of SHA2011 policy analysis based on health financing system and health policy subsystem was established. 2. The index system of SHA2011 policy analysis framework was constructed. The main research process was divided into two steps. The first step was to develop SHA2011 index group by using "literature research method, comprehensive method and cross method". This paper summarizes the common characteristics of the "indicators" and the "indicators" of the traditional total health expenditure, expands the development of SHA2011 indicators (groups) and explores the significance of its policy application. Firstly, according to the main research content (financing function) of SHA2011, the index group of SHA2011 was docked with the conceptual framework of this study, and the index system of SHA2011 policy analysis was constructed from the perspective of "overall situation" of health financing system. The common result is to evaluate the implementation effect of the "holistic" health policy (group) through the SHA2011 index system. The framework constructs the SHA2011 analysis and evaluation method for the "holistic" health financing policy. Secondly, the "policy objectives" are refined according to the six policy subsystems by using the "index attribute grouping method - problem method and goal method". The target "matches the result" and "process" of the conceptual framework of this study respectively, and constructs the SHA2011 policy analysis framework index system based on the subsystem of policy issues. On the other hand, according to the needs of policy objectives, the SHA2011 index group is further supplemented to expand the significance of policy application. The framework constructs the SHA2011 analysis and evaluation method for "partial (specific)" health financing policy. 3. To study the status quo of SHA2011 index system. First, summarize the research involved in this study. And all the SHA2011 index groups, show its application in the conceptual framework of SHA2011 policy analysis, summarize the indicators of "not yet applied analysis" in the literature research of SHA2011 in China; secondly, summarize the status quo of the existing accounting data support system in Beijing SHA2011: on the one hand, summarize the existing accounting data support SHA201. 1. Indicator (group) lists the sources of the data tables. On the other hand, it lists the data that need to be supplemented for those indicators which have not yet been supported by accounting data. On the basis of the theory, this paper firstly demonstrates the embodiment of health financing objectives in the financing function, secondly demonstrates the close relationship between SHA2011 and health financing, and draws the following conclusions: "SHA2011 and health financing system show a similar process of health financing flow, SHA2011 can reflect the full function and objectives of health financing; Sufficiency, sustainability, equity, and efficiency can be used as the criteria for assessing health costs in SHA2011.2) This study creatively adjusted and constructed a "structure-process-result" analytical framework for SHA2011. First, through adjusting the framework elements (by "partially incorporating" the input elements of the traditional "concept" into the "process" of SHA2011), a suitable framework for SHA2011 was formed. The narrow structure index and the broad process index are represented by the capital formation cost and the recurrent health cost of SHA2011 respectively. Secondly, through the discussion of the "results" index, the health financing target is selected as the "system results" index to complete the construction of the conceptual framework of SHA2011 policy analysis. The dialectical relationship between process and result is proposed as follows: the structure of SHA2011 and process can not only reflect the result individually, but also complement each other, and it is easier to obtain the optimal result when changing in the same direction. The conceptual framework of SHA2011 policy analysis not only provides the evaluation criteria and analysis ideas for the analysis and policy application of SHA2011, but also suggests that the independent capital formation costs and recurrent health costs of SHA2011 should be analyzed jointly in the analysis and research. In the study of policy application, we pay attention to the relationship between the two, and replace the "split" analysis with "joint" analysis, which provides a new idea for the evaluation and analysis of SHA2011. 2. This study expands and develops the SHA2011 index (group), deduces and explores its policy application significance, and provides a reference for the policy application transformation of SHA2011 data. On the one hand, it studies the expanded dimension classification caliber of SHA2011, constructs the SHA2011 index (group) and its possible policy application scenarios; on the other hand, it grasps the existing data and accounting process of SHA2011, expands the analysis angle, and creates a new policy application scenario. The new SHA2011 index and its application significance. The index system of SHA2011 policy analysis framework is constructed systematically to serve for policy evaluation and analysis. 1) The index system of policy analysis framework covering the main research contents of SHA2011 is constructed from the perspective of "overall situation" of health financing system. The index system of SHA2011 policy analysis framework based on "subsystem of policy issues" is constructed. The index system of SHA2011 policy analysis framework is constructed. The evaluation method of SHA2011 on "partial (specific)" health financing policy is constructed. 4. This study systematically summarizes the research status of SHA2011 index system, clarifies the blank points of SHA2011 research at this stage, and points out that the analysis should be done at present. The indicators used and those not yet analyzed and applied provide references for the future research direction of Beijing. Among them, the indicators that have not yet been analyzed and applied include those that have not yet been supported by the accounting data and those that have been supported by the accounting data. Meaning can provide directional guidance for the next step of accounting and analysis in SHA2011. On the other hand, this study expands the analysis angle and develops its policy application significance based on the available data for the index group supported by the existing accounting data system, which provides a reference for the further analysis of SHA2011.
【學(xué)位授予單位】：北京中醫(yī)藥大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R197.1
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本文編號：2236162