中低收入國家不同醫療保障制度設計對抵御疾病經濟風險的作用研究_《中國循證醫學雜志》

作者：

 于保榮 ¹ , 高靜 ¹ , 宮習飛 ¹ , 褚金花 ¹ , 高軍 ² , 閆贇 ¹ , 郭麗 ¹ , 孟慶躍 ¹

1. 山東大學衛生管理與政策研究中心（濟南 250012）；2. 衛生部統計信息中心（北京 100044）;

關鍵詞：

醫療保障制度疾病經濟風險中低收入國家系統評價

DOI：

10.7507/1672-2531.20080187

視頻：

導出 下載 收藏 掃碼 引用

摘要 全文 圖表 視頻 參考文獻 施引文獻 補充材料

目的　采用系統評價的方法對中低收入國家不同醫療保障制度抵抗經濟風險的制度安排進行總結和描述；對制度安排所產生不同效果的原因進行分析。
方法　由主題專家和檢索人員討論并試驗后確定檢索詞，共檢索24個電子數據庫、11個衛生機構網站和搜索引擎Google。納入所有對中低收入國家醫療保障制度對抵御疾病經濟風險進行評價的原始研究。按預先設計的數據提取表采集納入文獻的相關信息，而后加以分析和描述。
結果　所納入52篇文獻中，能夠抵御疾病經濟風險的56個制度設計歸結為以下六類：① 社區醫療保險；② 社會醫療保險；③ 衛生部門改革；④ 補助型保障；⑤ 使用者付費；⑥ 中國新型農村合作醫療。其中，42個的制度設計對抵御疾病經濟風險有正性作用，6個有負性影響，5個沒有影響，2個影響不明確。
結論　中低收入國家能夠有效抵御疾病經濟風險的制度設計歸結為：自付比例的設置方式，服務包的范圍和內容，對特定人群提供免費服務，在衛生服務可及性差的地區建立初級衛生保健團隊和中國的新型農村合作醫療制度。對低收入人群抵御疾病經濟風險起到有效影響的制度有：國家為窮人購買保險、向窮人提供免費服務和根據收入水平規定不同的費用自付比例。制度設計對抵御疾病經濟風險沒有發生作用的原因是，由于制度內和制度外多種因素的制約，而使制度在運行過程中偏離了初始目標。

引用本文： 于保榮,高靜,宮習飛,褚金花,高軍,閆贇,郭麗,孟慶躍. 中低收入國家不同醫療保障制度設計對抵御疾病經濟風險的作用研究. 中國循證醫學雜志, 2008, 08(10): 833-841. doi: 10.7507/1672-2531.20080187 復制

1.	ILO. Extending social protection in health through communitybased health organizations evidence and challenges. DiscussionPaper 2002. Access from: www.ilo.org/publns.
2.	Lagarde M. Evidence from systematic reviews to inform decisionmaking regarding financing mechanism that improve access tohealth services for poor people.
3.	Ekman B. Community-based health insurance in low-incomecountries: a systematic review of the evidence. Health Policy Plan, 2004, 19 (5): 249-270.
4.	WHO Regional Office for South-East Asia. Social Health Insurance.
5.	Wagstaff A, Lindelow M. Can Insurance Increase Financial Risk? The Curious Case of Health Insurance in China. The World Bank USA, 2005.
6.	Zhu L. Effects of Rural Medical Financial Assistance in China. China & World Economy, 2007, 15(2): 16-28.
7.	王桂林, 孟慶躍, 成剛, 等. 沈陽市和成都市貧困醫療救助項目實施效果評價. 中國衛生經濟, 2005, 24(10): 74-75.
8.	Sun XY, Jackson S, Carmichael G, et al. Catastrophic Paymentand Health Protection in Rural China-Impact of New CooperativeMedical Scheme in Shandong Province. Discussion Paper No.344, 2007.
9.	Jackson S, Sleigh AC, Peng L, et al. Low Premium Insurance Compared to the Out-of-Pocket System.
10.	徐潤龍, 葉真, 曾國經, 等. 浙江省三縣新型農村合作醫療方案對解決“因病致貧”問題的作用評價. 中國衛生經濟, 2006, 25(278).
11.	朱偉明. 寶山區新型農村合作醫療籌資、運行機制研究. 中國農村衛生事業管理, 2005, 25(9): 8-10.
12.	常文虎, 趙勁紅, 鄒聲金, 等. 大病醫療統籌對農民災難性衛生支出作用的案例研究. 中國初級衛生保健, 2005, 228(2): 2-6.
13.	張繼偉, 楊永萌, 張紅麗, 等. 黑龍江省新型農村合作醫療試點縣補償方式調查研究. 中國衛生經濟, 2005, 24(4): 56-59.
14.	鐘邃, 周曉媛, 曹念東, 等. 成都市新型農村合作醫療家庭賬戶效果分析. 現代預防醫學, 2006, 33(1): 18-20.
15.	王承利, 郭泅梅. 平陰縣玫瑰鎮實行新型農村合作醫療情況分析.社區醫學, 2006, 4(1): 3.
16.	賈曉蓉, 陳興寶, 張文忠, 等. 上海市郊區新型農村合作醫療防止因病致貧能力研究. 衛生經濟研究, 2006, (1): 34-35.
17.	胡善聯. 全國新型農村合作醫療制度的籌資運行狀況. 中國衛生經濟, 2004, 23(9): 24-25.
18.	魏晶晶, 呂柏, 斯日爾格楞, 等. 新疆地區6個試點縣合作醫療籌資水平及補償方案分析. 中國衛生事業管理, 2006, 6: 367-368.
19.	陳迎春, 徐錫武, 王蓉, 等. 新型農村合作醫療減緩“因病致貧”效果測量. 中國衛生經濟, 2005, 24(8): 26-28.
20.	顏媛媛, 張林秀, 羅斯高, 等. 新型農村合作醫療的實施效果分析——來自中國5省101個村的實證研究. 中國農村經濟, 2006,(5): 64-71.
21.	崔欣, 羅力, 李春芳, 等. 新型農村合作醫療降低就醫經濟風險的作用. 中國衛生資源, 2005, 8(6): 253-255.
22.	Devadasan N, Criel B, Van Damme W, et al. Indian communityhealth insurance schemes provide partial protection againstcatastrophic health expenditure. BMC Health Services Research, 2007.
23.	Ranson MK. The SEWA Medical Insurance Fund in India. HealthFinancing for Poor People, 2004, 275-292.
24.	Ranson MK. Reduction of catastrophic health care expendituresby a community-based health insurance scheme in Gujarat, India:current experiences and challenges. Bulletin of the World HealthOrganization, 2002, 80(8): 613-621.
25.	Gumber A. Hedging the health of the poor: the case for communityfinancing in India. The International Bank for Reconstruction andDevelopment/ The World Bank, 2001.
26.	Gumber A. The Potential Role of Community Financing in India.The world bank, 2004.
27.	Ranson MK. The impact of sewa’s medical insurance fundon hospital utilization and expenditure health. Nutrition andPopulation Discussion Paper, 2001.
28.	Wagstaffa A. Health Insurance for the Poor: Initial Impacts ofVietnam’s Health Care Fund for the Poor. World Bank PolicyResearch Working Paper, 2007.
29.	Wagstaff A, Pradhan M. Health Insurance Impacts on Health and Nonmedical Consumption in a Developing Country. World BankPolicy Research Working Paper, 2005.
30.	Sepehri A, Sarma S, Simpson W. Does non-profit health insurancereduce financial burden? Evidence from the Vietnam Living Standards Survey panel. Paper to be presented at the 38th Annual Meetings of the CEA at Ryerson University Toronto, 2004.
31.	Castano RA, Arbelaez JJ, Giedion UB, et al. Equitable financing, outof-pocket payments and the role of health care reform in Colombia. Health Policy and Planning, 2002, 17(1): 5-11.
32.	Ruiz F, Amaya L, Venegas S. Progressive segmented healthinsurance: Colombian health reform and access to health services. Health Econmy, 2007, 16: 3-18.
33.	Castaco R, Zambrano A. Financial protection for the poor in Colombia: the effects of a subsidized health insurance scheme. Economa No 12, 2007.
34.	Koren R, Steinberg DM. The impact of filipino micro health insurance units on income-related equality of access to healthcare. Health Policy, 2006, 77: 304-317.
35.	Gertler P, Solon O. Who Benefits From Social Health Insurance? Evidence from the Philippines, 2002.
36.	Gotsadzea G, Zoidze A, Vasadze O. Reform strategies in Georgia andtheir impact on health care provision in rural areas: evidence from ahousehold survey. Social Science & Medicine, 2005, 60: 809-821.
37.	Gotsadze G, Bennett S, Ranson K, et al. Health care-seeking behaviour and out-of-pocket payments in Tbilisi, Georgia. HealthPolicy Plan, 2005, 20(4): 232-242.
38.	Derriennic Y, Wolf K, Kiwanuka-Mukiibi P. An Assessment of Community-Based Health Financing Activities in Uganda. The Partners for Health Reformplus Project (PHRplus), 2005.
39.	Xu K, Evans DB, Kadama P, et al. Understanding the impactof eliminating user fees: utilization and catastrophic healthexpenditures in Uganda. Soc Sci Med, 2006, 62(4):866-876.
40.	Schneider P, Diop F. Community-Based Health Insurance inRwanda. The world bank, 2004.
41.	Schneider P, Diop F. Synopsis of Results on the Impact of Community-Based Health Insurance on Financial Accessibility to Health Care in Rwanda. Discussion Paper, Health, Nutrition andPopulation (HNP), 2001.
42.	Ju?tting JP. Financial Protection and Access to Health Care in Rural Areas of Senegal. Health Financing for Poor People--ResourceMobilization and Risk Sharing, 2004, chapter6: 232-247.
43.	Asfaw A, Ju?tting JP. The Role of Health Insurance in Poverty Reduction: Empirical Evidence From Senegal. Intl Journal of PublicAdministration, 2007, (30): 835-858.
44.	Jacobs B, Price N. Improving access for the poorest to public sector health services: insights from Kirivong Operational Health Districtin Cambodia. Health Policy Plan, 2006, 21(1): 27-39.
45.	Jacobs B, Price N. The impact of the introduction of user fees at a district hospital in Cambodia. Health Policy Plan, 2004, 19(5):310-321.
46.	Baschieri A, Falkingham J. Formalizing informal payments: the progress of health reform in Kyrgyzstan. Central Asian Survey, 2006,25(4): 441-460.
47.	Falkingham J. Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan. Social Science & Medicine, 2004, 58:247-258.
48.	Ekman B. Catastrophic health payments and health insurance: Some counterintuitive evidence from one low-income country. HealthPolicy, 2007, (83): 304-313.
49.	Diop F, Yazbeck A, Bitrán R. The impact of alternative cost recovery schemes on access and equity in Niger. Health Policy Plan, 1995, 10(3): 223-240.
50.	Moens F. Design, implementation, and evaluation of a community financing scheme for hospital care in developing countries: a prepaidhealth plan in the Bwamanda health zone, Zaire. Soc Sci Med, 1990, 30(12): 1319-1327.
51.	Anonymous. Health Care Utilization, Expenditures, and Insurance: Household Survey Findings from Suez Governorate, Egypt. Partnersfor Health Reformplus (PHRplus), 2005.
52.	Sulzbach S, Garshong B, Owusu-Banahene G. Evaluating the Effects of the National Health Insurance Act in Ghana. Baseline Report. Partners for Health Reformplus, 2005.
53.	Huber JH. Ensuring access to health care with the introduction of user fees: a Kenyan example. Health Economics Research, 1993, 36(4):485-494.
54.	Msuya JM, Ju?tting JP, Asfaw A. Impacts of Community Health Insurance Schemes on Health Care Provision in Rural Tanzania. Zentrum fu?r Entwicklungsforschung Center for DevelopmentResearch, 2004.
55.	Knaul FM, Arreola-Ornelas H, Méndez-Carniado O, et al. Evidence is good for your health system: policy reform to remedy catastrophicand impoverishing health spending in Mexico. Lancet, 2006, 368(9549): 1828-1841.
56.	Habichi J, Xu K, Couffinhal A, et al. Detecting changes in financial protection: creating evidence for policy in Estonia. Health Policy andPlanning, 2006, 21(6): 421-431.

1. ILO. Extending social protection in health through communitybased health organizations evidence and challenges. DiscussionPaper 2002. Access from: www.ilo.org/publns.
2. Lagarde M. Evidence from systematic reviews to inform decisionmaking regarding financing mechanism that improve access tohealth services for poor people.
3. Ekman B. Community-based health insurance in low-incomecountries: a systematic review of the evidence. Health Policy Plan, 2004, 19 (5): 249-270.
4. WHO Regional Office for South-East Asia. Social Health Insurance.
5. Wagstaff A, Lindelow M. Can Insurance Increase Financial Risk? The Curious Case of Health Insurance in China. The World Bank USA, 2005.
6. Zhu L. Effects of Rural Medical Financial Assistance in China. China & World Economy, 2007, 15(2): 16-28.
7. 王桂林, 孟慶躍, 成剛, 等. 沈陽市和成都市貧困醫療救助項目實施效果評價. 中國衛生經濟, 2005, 24(10): 74-75.
8. Sun XY, Jackson S, Carmichael G, et al. Catastrophic Paymentand Health Protection in Rural China-Impact of New CooperativeMedical Scheme in Shandong Province. Discussion Paper No.344, 2007.
9. Jackson S, Sleigh AC, Peng L, et al. Low Premium Insurance Compared to the Out-of-Pocket System.
10. 徐潤龍, 葉真, 曾國經, 等. 浙江省三縣新型農村合作醫療方案對解決“因病致貧”問題的作用評價. 中國衛生經濟, 2006, 25(278).
11. 朱偉明. 寶山區新型農村合作醫療籌資、運行機制研究. 中國農村衛生事業管理, 2005, 25(9): 8-10.
12. 常文虎, 趙勁紅, 鄒聲金, 等. 大病醫療統籌對農民災難性衛生支出作用的案例研究. 中國初級衛生保健, 2005, 228(2): 2-6.
13. 張繼偉, 楊永萌, 張紅麗, 等. 黑龍江省新型農村合作醫療試點縣補償方式調查研究. 中國衛生經濟, 2005, 24(4): 56-59.
14. 鐘邃, 周曉媛, 曹念東, 等. 成都市新型農村合作醫療家庭賬戶效果分析. 現代預防醫學, 2006, 33(1): 18-20.
15. 王承利, 郭泅梅. 平陰縣玫瑰鎮實行新型農村合作醫療情況分析.社區醫學, 2006, 4(1): 3.
16. 賈曉蓉, 陳興寶, 張文忠, 等. 上海市郊區新型農村合作醫療防止因病致貧能力研究. 衛生經濟研究, 2006, (1): 34-35.
17. 胡善聯. 全國新型農村合作醫療制度的籌資運行狀況. 中國衛生經濟, 2004, 23(9): 24-25.
18. 魏晶晶, 呂柏, 斯日爾格楞, 等. 新疆地區6個試點縣合作醫療籌資水平及補償方案分析. 中國衛生事業管理, 2006, 6: 367-368.
19. 陳迎春, 徐錫武, 王蓉, 等. 新型農村合作醫療減緩“因病致貧”效果測量. 中國衛生經濟, 2005, 24(8): 26-28.
20. 顏媛媛, 張林秀, 羅斯高, 等. 新型農村合作醫療的實施效果分析——來自中國5省101個村的實證研究. 中國農村經濟, 2006,(5): 64-71.
21. 崔欣, 羅力, 李春芳, 等. 新型農村合作醫療降低就醫經濟風險的作用. 中國衛生資源, 2005, 8(6): 253-255.
22. Devadasan N, Criel B, Van Damme W, et al. Indian communityhealth insurance schemes provide partial protection againstcatastrophic health expenditure. BMC Health Services Research, 2007.
23. Ranson MK. The SEWA Medical Insurance Fund in India. HealthFinancing for Poor People, 2004, 275-292.
24. Ranson MK. Reduction of catastrophic health care expendituresby a community-based health insurance scheme in Gujarat, India:current experiences and challenges. Bulletin of the World HealthOrganization, 2002, 80(8): 613-621.
25. Gumber A. Hedging the health of the poor: the case for communityfinancing in India. The International Bank for Reconstruction andDevelopment/ The World Bank, 2001.
26. Gumber A. The Potential Role of Community Financing in India.The world bank, 2004.
27. Ranson MK. The impact of sewa’s medical insurance fundon hospital utilization and expenditure health. Nutrition andPopulation Discussion Paper, 2001.
28. Wagstaffa A. Health Insurance for the Poor: Initial Impacts ofVietnam’s Health Care Fund for the Poor. World Bank PolicyResearch Working Paper, 2007.
29. Wagstaff A, Pradhan M. Health Insurance Impacts on Health and Nonmedical Consumption in a Developing Country. World BankPolicy Research Working Paper, 2005.
30. Sepehri A, Sarma S, Simpson W. Does non-profit health insurancereduce financial burden? Evidence from the Vietnam Living Standards Survey panel. Paper to be presented at the 38th Annual Meetings of the CEA at Ryerson University Toronto, 2004.
31. Castano RA, Arbelaez JJ, Giedion UB, et al. Equitable financing, outof-pocket payments and the role of health care reform in Colombia. Health Policy and Planning, 2002, 17(1): 5-11.
32. Ruiz F, Amaya L, Venegas S. Progressive segmented healthinsurance: Colombian health reform and access to health services. Health Econmy, 2007, 16: 3-18.
33. Castaco R, Zambrano A. Financial protection for the poor in Colombia: the effects of a subsidized health insurance scheme. Economa No 12, 2007.
34. Koren R, Steinberg DM. The impact of filipino micro health insurance units on income-related equality of access to healthcare. Health Policy, 2006, 77: 304-317.
35. Gertler P, Solon O. Who Benefits From Social Health Insurance? Evidence from the Philippines, 2002.
36. Gotsadzea G, Zoidze A, Vasadze O. Reform strategies in Georgia andtheir impact on health care provision in rural areas: evidence from ahousehold survey. Social Science & Medicine, 2005, 60: 809-821.
37. Gotsadze G, Bennett S, Ranson K, et al. Health care-seeking behaviour and out-of-pocket payments in Tbilisi, Georgia. HealthPolicy Plan, 2005, 20(4): 232-242.
38. Derriennic Y, Wolf K, Kiwanuka-Mukiibi P. An Assessment of Community-Based Health Financing Activities in Uganda. The Partners for Health Reformplus Project (PHRplus), 2005.
39. Xu K, Evans DB, Kadama P, et al. Understanding the impactof eliminating user fees: utilization and catastrophic healthexpenditures in Uganda. Soc Sci Med, 2006, 62(4):866-876.
40. Schneider P, Diop F. Community-Based Health Insurance inRwanda. The world bank, 2004.
41. Schneider P, Diop F. Synopsis of Results on the Impact of Community-Based Health Insurance on Financial Accessibility to Health Care in Rwanda. Discussion Paper, Health, Nutrition andPopulation (HNP), 2001.
42. Ju?tting JP. Financial Protection and Access to Health Care in Rural Areas of Senegal. Health Financing for Poor People--ResourceMobilization and Risk Sharing, 2004, chapter6: 232-247.
43. Asfaw A, Ju?tting JP. The Role of Health Insurance in Poverty Reduction: Empirical Evidence From Senegal. Intl Journal of PublicAdministration, 2007, (30): 835-858.
44. Jacobs B, Price N. Improving access for the poorest to public sector health services: insights from Kirivong Operational Health Districtin Cambodia. Health Policy Plan, 2006, 21(1): 27-39.
45. Jacobs B, Price N. The impact of the introduction of user fees at a district hospital in Cambodia. Health Policy Plan, 2004, 19(5):310-321.
46. Baschieri A, Falkingham J. Formalizing informal payments: the progress of health reform in Kyrgyzstan. Central Asian Survey, 2006,25(4): 441-460.
47. Falkingham J. Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan. Social Science & Medicine, 2004, 58:247-258.
48. Ekman B. Catastrophic health payments and health insurance: Some counterintuitive evidence from one low-income country. HealthPolicy, 2007, (83): 304-313.
49. Diop F, Yazbeck A, Bitrán R. The impact of alternative cost recovery schemes on access and equity in Niger. Health Policy Plan, 1995, 10(3): 223-240.
50. Moens F. Design, implementation, and evaluation of a community financing scheme for hospital care in developing countries: a prepaidhealth plan in the Bwamanda health zone, Zaire. Soc Sci Med, 1990, 30(12): 1319-1327.
51. Anonymous. Health Care Utilization, Expenditures, and Insurance: Household Survey Findings from Suez Governorate, Egypt. Partnersfor Health Reformplus (PHRplus), 2005.
52. Sulzbach S, Garshong B, Owusu-Banahene G. Evaluating the Effects of the National Health Insurance Act in Ghana. Baseline Report. Partners for Health Reformplus, 2005.
53. Huber JH. Ensuring access to health care with the introduction of user fees: a Kenyan example. Health Economics Research, 1993, 36(4):485-494.
54. Msuya JM, Ju?tting JP, Asfaw A. Impacts of Community Health Insurance Schemes on Health Care Provision in Rural Tanzania. Zentrum fu?r Entwicklungsforschung Center for DevelopmentResearch, 2004.
55. Knaul FM, Arreola-Ornelas H, Méndez-Carniado O, et al. Evidence is good for your health system: policy reform to remedy catastrophicand impoverishing health spending in Mexico. Lancet, 2006, 368(9549): 1828-1841.
56. Habichi J, Xu K, Couffinhal A, et al. Detecting changes in financial protection: creating evidence for policy in Estonia. Health Policy andPlanning, 2006, 21(6): 421-431.

《中國循證醫學雜志》

中低收入國家不同醫療保障制度設計對抵御疾病經濟風險的作用研究

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《中國循證醫學雜志》

中低收入國家不同醫療保障制度設計對抵御疾病經濟風險的作用研究

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