合作醫(yī)療保險(xiǎn)改革與中國(guó)農(nóng)村地區(qū)鄉(xiāng)鎮(zhèn)衛(wèi)生院效率外文翻譯

1、<p>　　畢業(yè)論文外文資料翻譯</p><p>　　題 目 合作醫(yī)療保險(xiǎn)改革與中國(guó)農(nóng)村地區(qū)</p><p>　　鄉(xiāng)鎮(zhèn)衛(wèi)生院效率：從調(diào)查數(shù)據(jù)分析</p><p>　　學(xué) 院 經(jīng)濟(jì)學(xué)院 </p><p>　　專 業(yè) 經(jīng)濟(jì)學(xué) <

2、;/p><p>　　班 級(jí) 0901 </p><p>　　學(xué) 生 王強(qiáng) </p><p>　　學(xué) 號(hào) 20092221328 </p><p>　　指導(dǎo)教師 王雷

3、 </p><p>　　二〇一三年四月十九日</p><p>　　China Economic Review， 2013（4）：13-26.</p><p>　　Health insurance reform and efficiency of township hospitals in rural China:An analysis from

4、survey data</p><p>　　Martine Audibert, Jacky Mathonnat, Aurore Pelissier, Xiao Xian Huang, Anning Ma</p><p><b>　　ABSTRACT</b></p><p>　　In the rural health-care organizat

5、ion of China, township hospitals ensure the delivery of medical services above village health stations and below county hospitals. Particularly damaged by the economic reforms implemented from 1975 to the end of the 1990

6、s, the efficiency of township hospitals has been questioned, mainly because of the implementation since 2003 of the reform of health insurance in rural areas (New Rural Cooperative Medical Scheme). From a database of 24

7、randomly selected township</p><p>　　As curative and preventive medical services delivered at township hospital level use different production processes, two data envelopment analysis models are estimated wit

8、h different orientations to compute scores. The results show that technical efficiency has declined over time.The factors explaining technical efficiency are mainly environmental characteristics rather than internal ones

9、. Among these environmental factors, NRCMS have in average a negative effect on the evolution of THs efficien</p><p>　　1.Introduction</p><p>　　In the rural Chinese healthcare system, township ho

10、spitals (THs) play an essential role: they represent the main providers of primary healthcare in rural areas (Hillier & Shen, 1996). THs constitute the intermediate level of healthcare facilities and ensure the link

11、between village health stations at the grassroots level and county or above-level hospitals. They supervise healthcare delivery at the level of village health stations, and act as gate keepers, orienting patients toward

12、higher health</p><p>　　The Chinese rural healthcare system has greatly changed since the 1950s. From 1950 to 1975, China achieved significant improvements in health outcomes, thanks to the definition of an e

13、fficient three-tier system of healthcare delivery and a successful community-based rural health insurance scheme (Hsiao, 1995; World Bank, 1997). However, the economic transition (1975–1990) caused the deterioration of t

14、hese two pillars of the rural healthcare system (Liu, Xu, & Wang, 1996; Wagstaff, Lindelow, Wang</p><p>　　Since 2003, the implementation of the New Rural Cooperative Medical Scheme (NRCMS) has served mai

15、nly two objectives.The first one is to offer an insurance system to the rural population, in order to lower the financial barrier to accessing the healthcare system and to improve the rural population's health (Wagst

16、aff, Lindelow, Wang, & Zhang, 2009). The second one is to make the THs, which suffered from the economic liberalization, more attractive by re-orientating patients toward this level.</p><p>　　The questio

17、n of the THs' efficiency is crucial, with regard to their strategic position in the healthcare delivery chain and the changes they experienced over the preceding years, but also in a context of scarce resources, of v

18、ertical and horizontal competition and health insurance reform. By targeting THs more than other health facilities in Weifang Prefecture, on which this study is focused, the NRCMS can influence the activity and the effic

19、iency of these facilities. The main channels are the </p><p>　　This study investigates technical efficiency by examining the production process of healthcare services in a sample of 24 randomly selected THs,

20、 observed over the period 2000–2008 in rural areas of Weifang Prefecture in China. According to the reviews of</p><p>　　Hollingsworth (2003) and O'Neill, Rauner, Heidenberger, and Kraus (2008), the liter

21、ature on the efficiency of health facilities mainly concentrates on North American and European case studies. But there is a growing literature on developing countries, such as Ersoy,</p><p>　　Kavuncubasi, O

22、zcan and Harris (1997) for Turkey, La Forgia and Couttolenc (2008) for Brasil, Hajialiafzali,Moss and Mahmood (2007) for Iran, Kirigia, Emrouznejad and Sambo (2002) for Kenya, Puenpatom and Rosenman (2008) for Thailand,

23、among others. In addition, there are two articles related to technical efficiency in Taiwan (Chang, 1998; Chang, Cheng, & Das, 2004), and two recent studies which examined hospital efficiency in China using a Data En

24、velopment Analysis (DEA) approach (Hu, Qi, & Yang,</p><p><b>　　2. Data</b></p><p>　　The original dataset covers 24 randomly selected THs of Weifang Prefecture, in Shandong Provin

25、ce (about 14% of total THs in Weifang Prefecture) observed over a nine-year period, from 2000 to 2008. Information was collected from the Weifang Health Bureau database and the registers/books of the THs during the third

26、 quarter of 2009 in collaboration with the Weifang Medical University and Chinese authorities. Data were checked and when necessary new investigations were implemented in THs and complet</p><p>　　The size of

27、 the THs is relatively small with on average 39 beds, 45 curative medical staff and six preventive staff over the period.However, the number of beds varied from16 to 150, reflecting large disparities in the size of THs.

28、The dataset consists of nine central THs and 15 general THs. Overall, the size of THs, as measured by the human and physical resources available, increased over the period.</p><p>　　3. Technical efficiency&l

29、t;/p><p>　　3.1. Estimation of technical efficiency</p><p>　　Developed in 1957 by Farrell (1957), the concept of technical efficiency refers to the capacity of a decision making unit (DMU) to transf

30、orm a quantity of inputs into an amount of outputs. The technical efficiency of DMUs is studied through the framework of the efficiency frontiers (Førsund, Lovell Knox, & Schmidt,, 1980).</p><p>　　T

31、he parametric stochastic approach, Stochastic Frontier Analysis (SFA) and the non-parametric determinist approach, Data Envelopment Analysis (DEA) are the most employed methods in production frontier analysis literature.

32、 The first is used when the production technology is well-known. It is based on an econometric specification of the production technology, for which the shape is determined by micro-econometric theory. The second is base

33、d on a mathematical linear program comparing decision makin</p><p>　　Considering hospitals, their optimization behavior diverges from traditional neoclassical theory (Hollingsworth, Dawson, &Maniadakis,

34、1999). Thus, the difficulty in assessing the nature of the optimization behavior of hospitals leads to a poorly known shape of the production function and pushes many practitioners to prefer a nonparametric approach such

35、 as DEA rather than the parametric SFA. In fact, DEA digs out the shape of the production frontier from the data and so does not require assumptio</p><p>　　3.2. The DEA models</p><p>　　As the pu

36、rpose is to model the production function of the DMUs, DEA requires the specification of the inputs used to produce the outputs, the orientation of the model, the nature of the returns to scale and the temporal dimension

37、 to run the DEA model.</p><p>　　THs deliver two main kinds of medical activities: curative and preventive healthcare services, which are characterized by two different production processes with two different

38、 objectives. Thus, two distinct DEA models are defined.</p><p>　　The model characterizing the production process of curative activities consists of one output and three inputs. THs delivered a large set of c

39、urative activities. Therefore, the number of outputs used in the DEA framework needs to be minimized,3 but the diversity of activities has to be taken into account. A composite index is calculated using a workload equiva

40、lent weighting system4 suggested by a Chinese experts committee5 and already used in a previous study (Audibert et al., 2008). Two main ca</p><p>　　The model characterizing the production process of preventi

41、ve activities consists of one output (the total volume of vaccinations delivered) and one input (the number of staff for preventive activities), as only human resources are used to produce preventive activities. The leve

42、l of production is previously defined by the government. The input orientation appears more suitable as THs can minimize their use of preventive resources in order to produce the target volume of preventive activities<

43、;/p><p>　　In both models, the case-mix was not taken into consideration because of the lack of data. Yet, the potential bias occurrence is not an important limitation to this specific study as THs are homogeneo

44、us in terms of disease treated (source: personal communication from Weifang Health Bureau). They are located in the same prefecture and face similar disease patterns. They belong to the same hierarchical level in the Chi

45、nese health delivery system and have therefore common missions defined by the go</p><p>　　4. Determinants of technical inefficiency</p><p>　　In line with the existing literature and the discussi

46、on with our Chinese partners, this paper focuses on two kinds of factors which can contribute to explain the efficiency level of THs: the internal characteristics of THs and the characteristics of the environment in whic

47、h THs are situated. Two Tobit models are estimated, one for efficiency scores calculated from the curative DEA model and one from the preventive DEA model, as explaining factors may differ for both estimations.</p>

48、<p>　　4.1. Internal factors</p><p>　　The composition of the staff (balance between qualified and unqualified staff), the staff work load and staff incentives are considered as important channels for t

49、echnical efficiency (Puenpatom & Rosenman, 2008; Yip et al., 2010). Variables are different according to the production process. We consider the proportion of qualified staff in the total staff for the regression on

50、the curative technical efficiency as a high ratio is expected to have an attractive effect on patients. The number of hou</p><p>　　The efficiency of THs may be subjected to financial constraints (Preker &

51、; Harding, 2003), creating a hard or a “soft budget constraint” (SCB). As pointed out by Kornai (2009) (p. 119–120), SBC is “not a single event, (…) but a mental condition, present in the head—the thinking, the perceptio

52、n of a decision maker (…). There are grades of hardness and softness”. That means that indicators should be continuous, not discrete. Theoretical and empirical literatures provide us with some evidence showin</p>

53、<p>　　We then also take into consideration the potential effect that the efficiency of a TH in a specific production process (for example, in curative healthcare delivery) can also have an effect on the efficiency o

54、f this same TH in other production processes (for example, in preventive healthcare delivery). To assess cross services' potential additional effects on efficiency behavior in different production technologies, effic

55、iency scores of the curative DEA model are introduced into the regression o</p><p>　　4.2. Environmental factors</p><p>　　The structural characteristic of the township is measured by the density

56、of the population in the township. It can influence the demand addressed to the THs and thus the volume of medical services they delivered.</p><p>　　The relationship of the TH with its environment is measure

57、d by two sets of variables. The density of village health stations(measured by the number of village health stations per 10,000 households) and the distance of the TH to the nearest county hospital reflect the geographic

58、al environment of THs. The density of village health stations can have two opposite effects on the efficiency of THs. A negative effect may be expected as village health stations and THs might compete for the delivery of

59、 p</p><p>　　5. Discussion</p><p>　　Our results show that THs efficiency, which was in average moderate at the beginning of the period, followed over the period a general declining trend to reach

60、 a rather weak level, along with the NRCMS implementation, although some THs have increased their efficiency. In addition, the heterogeneity between counties, which was great, has increased over time. If this decline in

61、efficiency in our sample was due to a decline in overcrowding of staff, it could be seen as some kind of improvement in q</p><p>　　Therefore our results mean a challenge for health policy makers in Weifang,

62、in an overall context of limited resources and increasing needs, as they suggest that space for improvements in efficiency does exist at THs level, both for the curative and preventive care. However, and broadly speaking

63、, what we have figured out in the Weifang sample is not an unusual experience as we can see from the literature. Recently, the rather low efficiency in the hospital sector in China was also stressed by Ng</p><

64、p>　　5.1. Adopting a systemic approach</p><p>　　International experiences show that improving health facilities efficiency is very complex with many context specific dimensions. It needs a combination of (

65、i) strong “macro” organizational incentives, (ii) a payment system integrating criteria of performance and (iii) a set of “micro”—i.e. at hospital level—incentives. The issue of alignment or misalignment of incentives wi

66、th the policy objectives of the health authorities is a major challenge (but it was out of the scope of this study to analy</p><p>　　5.2. Cautious introduction of competition</p><p>　　Internatio

67、nal experiences from developing and industrialized countries suggest that it is misleading to consider that organizing competition among health care providers (THs, village health stations and county hospitals for this s

68、tudy) to attract individual patients could be a sustainable approach in Weifang. Market competition may drive efficiency and quality either up or down, with uncertain effects on premiums(Gaynor, 2007). A recent study by

69、Chen and Cheng (2010) fromthe Taiwan single-payer </p><p>　　In contrast, organizing providers (THs) to compete for contracts with well informed purchasers (NRCMS) seems to be apromising approach to promoting

70、 incentives to deliver good quality of care while improving efficiency (cf. for example Preker &Harding, 2003, Wagstaff, Lindelow, Jun, Ling, & Juncheng, 2009). Then the health authorities in Weifang should push

71、the NRCMS to become active health care purchasers through contracting, instead of being more or less passive payers. That means that the regu</p><p>　　5.3. Lets THs managers manage</p><p>　　Comp

72、etition, contracts and financial discipline cannot drastically change THs' performance unless managers have sufficient regulated autonomy and authority to alter hospital behavior. More autonomy would be a robust driv

73、er to foster the efficiency of THs and make managers more accountable. However, regarding international experience, it is clear that THs autonomy won't be apanacea. To find the right balance between autonomy and trad

74、itional regulation is challenging. The Brazilian experience, for</p><p>　　5.4. Rationalizing THs health care supply at county level</p><p>　　The low level of staff productivity of numerous THs i

75、n our sample raises the issue of the size of each TH locally, and that of the global capacity of the supply of TH type of care at the county level. Our data and findings suggest a substantial room to rationalize the heal

76、th care supply within counties—including reducing the capacity of some TH—in order to improve THs efficiency. In that field, a related caveat merits also attention in Weifang: improving referral. Not only does a function

77、ing ref</p><p>　　5.5. Considering incentives in THs payment mechanisms as a tool</p><p>　　Payment mechanisms seem to be not enough used by the authorities as policy instruments for encouraging t

78、he performance and better efficiency of THs in Weifang. Moving that way implies to considerably reduce the share of the “fee-for-service” payments and to prefer methods of payment to THs tied to their activity and perfor

79、mance, along with increasing the reimbursement from NRCMS.12 A consistent finding from the international literature is that an optimal balance between cost and quality requires</p><p>　　Our results suggest t

80、hat THs operate under a SBC. Then it would be relevant to harden it, but with an adequate degree of flexibility and pragmatism. The zero markup policy for essential drugs, which does not allow additional margin when THs

81、sell drugs (their main source of income and an important factor in health care cost growth), and which has been adopted by the State Council in July 2009, is a promising step in that direction. To reduce the SBC, Weifang

82、 health authorities could also consider</p><p>　　6. Conclusion</p><p>　　During the last ten years, China has undertaken major health reforms that concern the supply and demand sides of healthcar

83、e,such as insurance in rural areas, the NRCMS which has been implemented in several waves. The NRCMS displays two major objectives. The first is to increase healthcare access for the rural population; the second to impro

84、ve the performance of the health system, more specifically, of THs, as it is clearly stated in Weifang Prefecture. </p><p>　　Our results show that THs efficiency, which was in average moderate at the beginni

85、ng of the period, followed over the period a general declining trend to reach a rather weak level, along with the NRCMS development, although some THs have increased their efficiency. In addition, the heterogeneity betwe

86、en counties, which was great, has increased over time. The factors explaining the evolution of technical efficiency are mainly environmental characteristics. Our results also show that the efficienc</p><p>　

87、　Our econometrics methods rely upon the international literature for analyzing efficiency, but further analysis could be conducted in a next stage by adding quality measures in order to have a more detailed assessment of

88、 the technical efficiency issues.</p><p>　　As far as the limitations of this study are concerned, one could consider that our results are based on a relatively small THs sample.But, as wementioned previously

89、, the sample concerns 14% of the entire Weifang Prefecture's THs. It is representative of the Weifang prefecture situation as we used a randomized process of selection of the hospitals studied in a nine-year survey p

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