中低收入国家不同医疗保障制度设计对抵御疾病经济风险的作用研究_《中国循证医学杂志》

作者：

 于保荣 ¹ , 高静 ¹ , 宫习飞 ¹ , 褚金花 ¹ , 高军 ² , 闫贇 ¹ , 郭丽 ¹ , 孟庆跃 ¹

1. 山东大学卫生管理与政策研究中心（济南 250012）；2. 卫生部统计信息中心（北京 100044）;

关键词：

医疗保障制度疾病经济风险中低收入国家系统评价

DOI：

10.7507/1672-2531.20080187

视频：

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摘要 全文 图表 视频 参考文献 施引文献 补充材料

目的　采用系统评价的方法对中低收入国家不同医疗保障制度抵抗经济风险的制度安排进行总结和描述；对制度安排所产生不同效果的原因进行分析。
方法　由主题专家和检索人员讨论并试验后确定检索词，共检索24个电子数据库、11个卫生机构网站和搜索引擎Google。纳入所有对中低收入国家医疗保障制度对抵御疾病经济风险进行评价的原始研究。按预先设计的数据提取表采集纳入文献的相关信息，而后加以分析和描述。
结果　所纳入52篇文献中，能够抵御疾病经济风险的56个制度设计归结为以下六类：① 社区医疗保险；② 社会医疗保险；③ 卫生部门改革；④ 补助型保障；⑤ 使用者付费；⑥ 中国新型农村合作医疗。其中，42个的制度设计对抵御疾病经济风险有正性作用，6个有负性影响，5个没有影响，2个影响不明确。
结论　中低收入国家能够有效抵御疾病经济风险的制度设计归结为：自付比例的设置方式，服务包的范围和内容，对特定人群提供免费服务，在卫生服务可及性差的地区建立初级卫生保健团队和中国的新型农村合作医疗制度。对低收入人群抵御疾病经济风险起到有效影响的制度有：国家为穷人购买保险、向穷人提供免费服务和根据收入水平规定不同的费用自付比例。制度设计对抵御疾病经济风险没有发生作用的原因是，由于制度内和制度外多种因素的制约，而使制度在运行过程中偏离了初始目标。

引用本文： 于保荣,高静,宫习飞,褚金花,高军,闫贇,郭丽,孟庆跃. 中低收入国家不同医疗保障制度设计对抵御疾病经济风险的作用研究. 中国循证医学杂志, 2008, 08(10): 833-841. doi: 10.7507/1672-2531.20080187 复制

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, 孟庆跃, 成刚, 等. 沈阳市和成都市贫困医疗救助项目实施效果评价. 中国卫生经济, 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.	徐润龙, 叶真, 曾国经, 等. 浙江省三县新型农村合作医疗方案对解决“因病致贫”问题的作用评价. 中国卫生经济, 2006, 25(278).
11.	朱伟明. 宝山区新型农村合作医疗筹资、运行机制研究. 中国农村卫生事业管理, 2005, 25(9): 8-10.
12.	常文虎, 赵劲红, 邹声金, 等. 大病医疗统筹对农民灾难性卫生支出作用的案例研究. 中国初级卫生保健, 2005, 228(2): 2-6.
13.	张继伟, 杨永萌, 张红丽, 等. 黑龙江省新型农村合作医疗试点县补偿方式调查研究. 中国卫生经济, 2005, 24(4): 56-59.
14.	钟邃, 周晓媛, 曹念东, 等. 成都市新型农村合作医疗家庭账户效果分析. 现代预防医学, 2006, 33(1): 18-20.
15.	王承利, 郭泅梅. 平阴县玫瑰镇实行新型农村合作医疗情况分析.社区医学, 2006, 4(1): 3.
16.	贾晓蓉, 陈兴宝, 张文忠, 等. 上海市郊区新型农村合作医疗防止因病致贫能力研究. 卫生经济研究, 2006, (1): 34-35.
17.	胡善联. 全国新型农村合作医疗制度的筹资运行状况. 中国卫生经济, 2004, 23(9): 24-25.
18.	魏晶晶, 吕柏, 斯日尔格楞, 等. 新疆地区6个试点县合作医疗筹资水平及补偿方案分析. 中国卫生事业管理, 2006, 6: 367-368.
19.	陈迎春, 徐锡武, 王蓉, 等. 新型农村合作医疗减缓“因病致贫”效果测量. 中国卫生经济, 2005, 24(8): 26-28.
20.	颜媛媛, 张林秀, 罗斯高, 等. 新型农村合作医疗的实施效果分析——来自中国5省101个村的实证研究. 中国农村经济, 2006,(5): 64-71.
21.	崔欣, 罗力, 李春芳, 等. 新型农村合作医疗降低就医经济风险的作用. 中国卫生资源, 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.	Jütting 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, Jütting 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, Jütting JP, Asfaw A. Impacts of Community Health Insurance Schemes on Health Care Provision in Rural Tanzania. Zentrum für 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, 孟庆跃, 成刚, 等. 沈阳市和成都市贫困医疗救助项目实施效果评价. 中国卫生经济, 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. 徐润龙, 叶真, 曾国经, 等. 浙江省三县新型农村合作医疗方案对解决“因病致贫”问题的作用评价. 中国卫生经济, 2006, 25(278).
11. 朱伟明. 宝山区新型农村合作医疗筹资、运行机制研究. 中国农村卫生事业管理, 2005, 25(9): 8-10.
12. 常文虎, 赵劲红, 邹声金, 等. 大病医疗统筹对农民灾难性卫生支出作用的案例研究. 中国初级卫生保健, 2005, 228(2): 2-6.
13. 张继伟, 杨永萌, 张红丽, 等. 黑龙江省新型农村合作医疗试点县补偿方式调查研究. 中国卫生经济, 2005, 24(4): 56-59.
14. 钟邃, 周晓媛, 曹念东, 等. 成都市新型农村合作医疗家庭账户效果分析. 现代预防医学, 2006, 33(1): 18-20.
15. 王承利, 郭泅梅. 平阴县玫瑰镇实行新型农村合作医疗情况分析.社区医学, 2006, 4(1): 3.
16. 贾晓蓉, 陈兴宝, 张文忠, 等. 上海市郊区新型农村合作医疗防止因病致贫能力研究. 卫生经济研究, 2006, (1): 34-35.
17. 胡善联. 全国新型农村合作医疗制度的筹资运行状况. 中国卫生经济, 2004, 23(9): 24-25.
18. 魏晶晶, 吕柏, 斯日尔格楞, 等. 新疆地区6个试点县合作医疗筹资水平及补偿方案分析. 中国卫生事业管理, 2006, 6: 367-368.
19. 陈迎春, 徐锡武, 王蓉, 等. 新型农村合作医疗减缓“因病致贫”效果测量. 中国卫生经济, 2005, 24(8): 26-28.
20. 颜媛媛, 张林秀, 罗斯高, 等. 新型农村合作医疗的实施效果分析——来自中国5省101个村的实证研究. 中国农村经济, 2006,(5): 64-71.
21. 崔欣, 罗力, 李春芳, 等. 新型农村合作医疗降低就医经济风险的作用. 中国卫生资源, 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. Jütting 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, Jütting 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, Jütting JP, Asfaw A. Impacts of Community Health Insurance Schemes on Health Care Provision in Rural Tanzania. Zentrum für 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.

《中国循证医学杂志》

中低收入国家不同医疗保障制度设计对抵御疾病经济风险的作用研究

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《中国循证医学杂志》

中低收入国家不同医疗保障制度设计对抵御疾病经济风险的作用研究

摘要 全文 图表 视频 参考文献 施引文献 补充材料

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