衛(wèi)生經(jīng)濟(jì)學(xué)：中國衛(wèi)生體制和醫(yī)藥衛(wèi)生改革情況

1

中國衛(wèi)生體制和改革情況介紹

HealthcareSystemandtheReform

inChina

22I.中國衛(wèi)生體制情況

ChineseHealthSystem

中國有關(guān)指標(biāo)(2015)

GeneralinformationofChina中國China人口總數(shù)Totalpopulation13.8億1.38billion國內(nèi)生產(chǎn)總值(美元)GDP(US$)9.9萬億9.9trillion人均國內(nèi)生產(chǎn)總值（美元）GDPpercapita

(US$)7200美元7200USD衛(wèi)生總費用占GDP比重TotalhealthexpenditureinGDP(%)6.0%4衛(wèi)生服務(wù)提供體系

HealthServiceDeliverySystem

已經(jīng)建立覆蓋城鄉(xiāng)居民的醫(yī)療衛(wèi)生服務(wù)體系。Healthservicedeliverysystemthatcoversallurbanandruralpopulation

hasbeenestablished.由醫(yī)院、公共衛(wèi)生機(jī)構(gòu)和基層醫(yī)療衛(wèi)生機(jī)構(gòu)組成Includinghospitals,publichealthinstitutionsandprimaryhealthcare

institutions.公立醫(yī)療衛(wèi)生機(jī)構(gòu)是我國醫(yī)療衛(wèi)生服務(wù)體系的主體，民營醫(yī)院迅速發(fā)展（2015年占醫(yī)院總數(shù)的52.5%）。Publicinstitutionsconstitutethepredominantpart,andprivatehospitals

developrapidlyandtheproportionofprivateproviderreached52.5%.優(yōu)先發(fā)展公共衛(wèi)生服務(wù)體系，城市社區(qū)衛(wèi)生服務(wù)體系和農(nóng)村醫(yī)療衛(wèi)生服務(wù)體系。Prioritiesaretodeveloppublichealthservicesystem,urbancommunityhealthservicesystemandruralhealthservicesystem.5衛(wèi)生資源和服務(wù)提供能力

HealthResourcesandServiceCapacity(2016)指標(biāo)Indicators總數(shù)Total醫(yī)院Hospital基層醫(yī)療機(jī)構(gòu)primaryhealthcareinstitutions公共衛(wèi)生機(jī)構(gòu)publichealthinstitutions

醫(yī)療衛(wèi)生機(jī)構(gòu)數(shù)（萬個）Healthinstitutions(10,000)98.42.892.13.2床位數(shù)（萬張）Hospitalbeds(10,000)701.5533.0141.423.6衛(wèi)生技術(shù)人員數(shù)（萬人）Healthworkforce(10,000)799.7507.1225.762.9每千人口醫(yī)療衛(wèi)生機(jī)構(gòu)床位（張）Hospitalbeds(per1000people)4.553.881.030.17每千人口執(zhí)業(yè)（助理）醫(yī)師數(shù)Doctors(per1000people)2.211.230.800.17每千人口注冊護(hù)士數(shù)（人）Nurses(per1000people)2.361.760.470.13診療人次數(shù)（億人次）totalvisits(tenbillion)77.030.843.4入院人數(shù)（億人）in-patients(tenbillion)2.11.60.46醫(yī)療保障體系MedicalInsuranceSystems城鎮(zhèn)職工醫(yī)療保險Urbanemployeebasichealthinsurance醫(yī)療救助MedicalAidSystem商業(yè)和補(bǔ)充醫(yī)療保險CommercialandComplementaryHealthInsurance城鎮(zhèn)居民醫(yī)療保險Urbannon-employedresidentsmedicalinsurance新型農(nóng)村合作醫(yī)療Newruralcooperativemedicalscheme基本醫(yī)療保障體系衛(wèi)生籌資體系

HealthFinancingSystem

特點：多渠道衛(wèi)生籌資體系

Characteristic:MixedFinancingSystem

社會衛(wèi)生支出Societycontribution40.3%政府衛(wèi)生支出governmentcontribution30.4%個人衛(wèi)生支出privatecontribution29.3%衛(wèi)生總費用構(gòu)成(2015)Proportionsoftotalhealthexpenditure(2015)8國家級CentralLevel省級Province市級Prefecture&City縣級County&District鄉(xiāng)鎮(zhèn)級Township（Neighborhood）國家衛(wèi)生健康委NationalHealthandFamilyPlanningCommission省級衛(wèi)生健康委ProvincialHFPC市級衛(wèi)生健康委HFPCofprefecture&city縣級衛(wèi)生健康委LocalHFPC衛(wèi)生行政管理體系HealthAdministrativeSystem

9衛(wèi)生和計劃生育、中醫(yī)藥事業(yè)發(fā)展的政策、法律法規(guī)、規(guī)劃的擬定Todrawuppolicy,lawsandregulations,aswellasdevelopmentplansofthehealthsector,familyplanningandtraditionalChinesemedicine推動醫(yī)藥衛(wèi)生體制改革Topushforwardhealthsystemreform疾病預(yù)防控制，公共衛(wèi)生應(yīng)急和醫(yī)療救援的組織指導(dǎo)Toorganizeandguidediseasepreventionandcontrol,publichealth

emergencyresponseandmedicalrescue醫(yī)療衛(wèi)生機(jī)構(gòu)和醫(yī)療服務(wù)的準(zhǔn)入監(jiān)管

Tosupervisemedicalinstitutionsandindustry-widemedicalservices.制定國家藥物政策和國家基本藥物制度Todevelopnationaldrugpolicyandnationalessentialdrugsystem衛(wèi)生綜合執(zhí)法監(jiān)督

Tobeinchargeofhealthlawenforcementandsupervision.衛(wèi)生和計劃生育科技發(fā)展和人才隊伍建設(shè)Todevelopthehumanresource,scienceandtechnologyforthehealthandfamilyplanningsector國家衛(wèi)生健康委的職責(zé)ResponsibilitiesofNHFPC1010

II.

中國衛(wèi)生體制改革情況

ReformofChinesehealthcaresystem2009年，國家啟動了新一輪醫(yī)改

總體目標(biāo)管理體制

運行機(jī)制投入機(jī)制價格形成機(jī)制監(jiān)管體制科技和人才保障信息系統(tǒng)法律制度總體目標(biāo)建設(shè)覆蓋城鄉(xiāng)居民的基本醫(yī)療衛(wèi)生制度，促進(jìn)人人享有基本醫(yī)療衛(wèi)生服務(wù)公共衛(wèi)生服務(wù)體系醫(yī)療服務(wù)體系醫(yī)療保障體系藥品供應(yīng)保障體系綜合監(jiān)督管理體系“158”頂層設(shè)計新一輪改革的主要原因

Mainreasonofthenewroundofreform醫(yī)療衛(wèi)生滯后于經(jīng)濟(jì)

Healthandeconomy公共衛(wèi)生滯后于醫(yī)療Publichealthandmedicalservices醫(yī)療保障滯后于醫(yī)療服務(wù)Medicalservicesandhealthinsurance城鄉(xiāng)和區(qū)域間存在差距Urbanandrural;differentareas改善群眾看病就醫(yī)的公平性、可及性、可負(fù)擔(dān)性和質(zhì)量Improvetheequality,accessibility,affordabilityandqualityofmedicalserviceUncoordinatedTarget

人民身體健康是全面建成小康社會的重要內(nèi)涵，是每一個人成長和實現(xiàn)幸福生活的重要基礎(chǔ)。People’healthisanimportantessentialforbuildingawell-offsocietyandisanimportantfoundationforpersonalgrowthandhappiness.習(xí)近平主席：

President

XiJinping

一、深化醫(yī)改的目標(biāo)和實施策略

I.Thegoalandimplementationstrategiesofhealthcaresystemreform

改革目標(biāo)：到2020年，建立健全覆蓋城鄉(xiāng)居民的基本醫(yī)療衛(wèi)生制度，為群眾提供安全、有效、方便、價廉的醫(yī)療衛(wèi)生服務(wù)，實現(xiàn)人人享有基本醫(yī)療衛(wèi)生服務(wù)。By2020,establishandimprovethebasichealthcaresystemcoveringurbanandruralresidents,andprovidethepeoplewithsecure,efficient,convenientandaffordablehealthcareservices,everyoneshallhaveaccesstothebasichealthcareservices.核心理念：基本醫(yī)療衛(wèi)生制度作為公共產(chǎn)品向全民提供。Ensurethatthebasichealthcaresystembepublicgoodsprovidedtotheentirepopulation.14基本原則：保基本、強(qiáng)基層、建機(jī)制。

Basicprinciples:ensuringbasicmedicalservices,strengtheningprimaryhealthinstitutions,establishingasoundmechanism.政府提供基本服務(wù)，社會主要提供非基本服務(wù)Governmentsprovidebasicmedicalservices,andthesocietymainlyprovidesnon-basicneeds.實施路徑：統(tǒng)籌安排、突出重點、循序推進(jìn)。Pathway:adoptastep-by-stepapproachtoreform,makingoverallplansandgivingprioritytokeyefforts.15第一階段（2009-2011）：打好基礎(chǔ)、形成框架、試點探索

Phase1(2009-2011):Laythefoundation,buildaframework,andstartwithpilots醫(yī)改五項重點工作Fivekeyreformprojects（2009-2011）推進(jìn)基本醫(yī)療保障制度建設(shè)Constructingbasicmedicalinsurancesystem建立國家基本藥物制度Establishinganationalessentialdrugsystem健全基層醫(yī)療衛(wèi)生服務(wù)體系Improvingthegrass-rootshealthcareservicessystem促進(jìn)基本公衛(wèi)服務(wù)均等化Promotingequalaccesstobasicpublichealthservices推進(jìn)公立醫(yī)院改革試點Promotingthepilotreformonpublichospitals16第二階段（2012-2015）：提升質(zhì)量、制度建設(shè)、全面推進(jìn)Phase2(2012-2015):Qualityimprovement,systemconstruction,andfullimplementation

ⅠIV統(tǒng)籌推進(jìn)其他醫(yī)改工作coordinatingand

promotingotherreformprojects2015年：To2015:服務(wù)更加公平可及；Healthservicesmorefairandaccessible;效率和水平更高；Moreefficientandeffective;健康水平進(jìn)一步改善。Healthlevelisfurtherdeveloped.鞏固完善基本藥物制度+基層運行新機(jī)制Consolidatingandimprovingnationalessentialdrugsystemandnewoperationmechanismsofgrass-rootshealthfacilities

Ⅱ積極推進(jìn)公立醫(yī)院改革Activelypromotethereformofpublichospitals

Ⅲ加快健全全民醫(yī)保體系

Acceleratingtheconstructionofuniversalmedicalinsurancesystem

Ⅰ17城鎮(zhèn)職工醫(yī)保UEMI城鎮(zhèn)居民醫(yī)保URMI新農(nóng)合RCMS覆蓋人口95%以上Coveringmorethan95%ofthepopulation進(jìn)展1：建立覆蓋全民的基本醫(yī)療保障制度Progress1:Abasicmedicalinsurancesystem政策范圍內(nèi)住院費用報銷比例達(dá)75%左右。Theinpatientreimbursementwithinthepolicyisover75%.建立城鄉(xiāng)居民大病保險制度，大病患者報銷比例在基本醫(yī)保基礎(chǔ)上提高10-15個百分點Reimbursementrateforcatastrophicdiseaseisincreasedby10-15percentagepointsontopofbasicmedicalcarecoverage三項基本醫(yī)保3basicmedicalinsurancesystems城鄉(xiāng)居民基本醫(yī)療保險城鄉(xiāng)居民大病保險國家基本藥物520種，銷售價格比改革前平均下降30%

520typesofdrugsonnationalessentialdruglist,theirpricesreducedby30%2012年版目錄2012Catalog化學(xué)藥品和生物制品Chemical&biologicalproducts中成藥Chinesetraditionalpatentmedicine進(jìn)展2：建立國家基本藥物制度和基層運行新機(jī)制Anationalessentialdrugsystemanditslocaloperationmechanism藥品供應(yīng)保障體系藥品供應(yīng)保障體系進(jìn)一步健全國家基本藥物制度公立醫(yī)療機(jī)構(gòu)藥品省級網(wǎng)上集中采購市場為主導(dǎo)的藥品價格形成機(jī)制

基層醫(yī)療衛(wèi)生機(jī)構(gòu)以取消以藥補(bǔ)醫(yī)機(jī)制為切入點，建立起公益性管理體制、長效性補(bǔ)償機(jī)制、競爭性用人機(jī)制、激勵性分配機(jī)制。

Reformthemechanismofcompensatingthemedicalcostthroughdrugsaleastheentrypoint,andestablishnon-profitmanagementmechanism,stablefinancialcompensationmechanism,competitivepersonnelmechanism,incentivedistributionmechanism.建立國家基本藥物制度和基層運行新機(jī)制Anationalessentialdrugsystemanditslocaloperationmechanism進(jìn)展3：健全基層醫(yī)療衛(wèi)生服務(wù)體系A(chǔ)CommunityHealthCareDeliverySystem醫(yī)改以來，中央財政投入1000多億元，加強(qiáng)基層硬件建設(shè)，基本實現(xiàn)一鄉(xiāng)一院、一村一室、15分鐘到達(dá)醫(yī)療衛(wèi)生機(jī)構(gòu)ThecentralgovernmentinvestedmorethanRMB100billion(15billionUS$)incommunityhealthfacilities,withthegoalsof1healthcenterforeachtownship,1clinicforeachvillageand15minutestoaccesstheheathfacilities.基層醫(yī)療衛(wèi)生服務(wù)模式發(fā)生轉(zhuǎn)變Servicemodeofgrass-rootshealthinstitutionschanges:由?？品?wù)轉(zhuǎn)向全科服務(wù)fromspecialtyservicestogeneralservices由疾病診治轉(zhuǎn)向健康管理fromtreatmenttohealthmanagement.500-911200-50072-200各省份公立醫(yī)院數(shù)量No.ofpublichospitals進(jìn)展4：健全公立醫(yī)院管理制度Apublichospitalmanagementsystem中國的公立醫(yī)院有1.3萬家,2015年診療人次27.1億

Chinahas13,000publichospitals.2.71billioncasesofdiagnosisandtreatmentswereperformedin2015.縣級公立醫(yī)院改革“三步走”推進(jìn)縣級公立醫(yī)院改革全國1977個縣（市）全面推開縣級公立醫(yī)院綜合改革2012年2014年2015年第一批311個試點縣（16.1%）第三批880個試點縣（45.6%）第二批737個試點縣（38.3%）全覆蓋公立醫(yī)院綜合改革持續(xù)拓展深化城市公立醫(yī)院改革2010年2014年2015年2016年2017年在17個城市啟動公立醫(yī)院改革試點增加到34個增加到100個增加到200個地級以上城市全面推開科學(xué)的管理體制和運行機(jī)制正在形成公立醫(yī)院綜合改革持續(xù)拓展深化

價格機(jī)制pricing管理體制managementsystem補(bǔ)償機(jī)制compensation收入分配remuneration藥品采購Drugprocurement支付方式Payment堅持公益性Publicgoodandwelfare監(jiān)管機(jī)制supervision公立醫(yī)院改革試點Pilotreformonpublichospitals200個國家級試點城市和所有縣級公立醫(yī)院啟動改革Thereformhasextendedto100nationallevelpilotcitiesandallcountylevelpublichospitals.2016年，試點城市公立醫(yī)院次均門診費用為240.8元，同比僅上漲2.4%；次均住院費用9081.7元，同比僅上漲2.8%，低于未改革的醫(yī)院。公立醫(yī)院收支結(jié)構(gòu)和費用增幅優(yōu)化醫(yī)院收入結(jié)構(gòu)持續(xù)優(yōu)化，全國公立醫(yī)院藥占比已從2010年的46.33%降至40%左右醫(yī)藥費用過快增長的勢頭得到初步遏制，政府辦醫(yī)療機(jī)構(gòu)收入增幅由2010年的18.97%降至10%左右；開展了12大類國家免費基本公共衛(wèi)生服務(wù)，2016年政府補(bǔ)助人均50元。Publichealthservicesin12categoriesareprovidedasnationalbasicpublicservices,forwhichthegovernmentandthegovernmentspecialsubsidypercapitais40Yuanin2015，freeforallresidents.進(jìn)展5：建立基本公共服務(wù)均等化制度Asystemofequalaccesstobasicpublichealthservices城鄉(xiāng)居民健康檔案管理healthrecordmanagement健康教育healtheducation預(yù)防接種

vaccination0～6歲兒童健康管理healthmanagementforchildrenagedfrom0to6孕產(chǎn)婦健康管理maternalhealthmanagement老年人健康管理healthmanagementforelderlypeople高血壓患者健康管理healthmanagementforpeoplelivingwithhypertensionⅡ型糖尿病患者健康管理healthmanagementforpeoplelivingwithtypeIIdiabetes重性精神疾病患者管理healthmanagementforpeoplewithseverementaldisorder

傳染病及突發(fā)公共衛(wèi)生事件報告和處理infectiousdisease&emergencypublichealthoutbreaks中醫(yī)藥健康管理TraditionalChinesemedicinehealthmanagement衛(wèi)生監(jiān)督協(xié)管服務(wù)規(guī)范regulationsforcoordinatedhealthsupervision深化醫(yī)改的成效

Achievements基本醫(yī)療衛(wèi)生制度框架初步建立。Thebasichealthcaresystemframeworkispreliminarilyestablished.公共衛(wèi)生服務(wù)、醫(yī)療服務(wù)、醫(yī)療保障和藥品供應(yīng)保障四大體系進(jìn)一步健全。

Publichealthservicesystem,healthcareservicesystem,medicalinsurancesystemanddrugsupplysystemarefurtherdeveloped.衛(wèi)生資源配置和利用得到優(yōu)化。Healthresourceallocationandutilizationareoptimized.29

深化醫(yī)改的成效:衛(wèi)生總費用結(jié)構(gòu)得到優(yōu)化Achievements:totalhealthexpenditurestructurewasoptimized.Year20082015Expenditure(CNY/billion)Ratio(%)Expenditure(CNY/billion)Ratio(%)政府衛(wèi)生支出governmentcontribution359.424.71247.530.4社會衛(wèi)生支出Societycontribution506.634.91650.740.3個人衛(wèi)生支付privatecontribution587.640.41199.329.3

改革取得的成效：居民健康水平不斷提高

Achievements:People’healthimproving.

產(chǎn)婦死亡率由醫(yī)改前的34.2/10萬下降到2015年的20.1/10萬Maternalmortalitydeclinedfrom34.2per100,000beforereformto20.1per100.000in2015改革取得的成效：居民健康水平不斷提高

Achievements:People’healthimproving嬰兒死亡率由醫(yī)改前的14.9‰下降到2.1‰

Infantmortalityratewasreducedfrom14.9‰to2.1‰改革面臨的挑戰(zhàn)

Challenges工業(yè)化、城鎮(zhèn)化進(jìn)程和人口老齡化趨勢加快，面臨重大傳染病和慢性病雙重威脅，醫(yī)療衛(wèi)生需求日益提高。醫(yī)療保障制度的完善，使居民醫(yī)療服務(wù)需求進(jìn)一步釋放。Wearefacingchallengesofindustrialization,urbanization,populationaging,severeinfectiousandchronicdisease,andgrowinghealthcareneeds.Developmentofmedicalinsurancesystemreleasedmoreneedsforhealthcareservices.隨著經(jīng)濟(jì)社會發(fā)展，中國衛(wèi)生資源特別是優(yōu)質(zhì)衛(wèi)生資源總體短缺、配置不均衡的矛盾突出。

Withthedevelopmentofsocietyandeconomy,healthresourcesespeciallythehigh-qualityresourcesareinshortageandresourceallocationisunreasonable.隨著深化醫(yī)改的推進(jìn)，體制性、結(jié)構(gòu)性等深層次矛盾暴露，各方面利益交織，改革難度加大。Asdeepeningofhealthcarereform,institutionalandstructuralconflictsareexposing,benefitinteractingmakereformmoredifficult.3334

III.醫(yī)改重點任務(wù)

Futurepriorityreformprograms

一人健康是立身之本，人民健康是立國之基。沒有全民健康，就沒有全面小康把人民健康放在優(yōu)先發(fā)展戰(zhàn)略地位努力全方位全周期保障人民健康進(jìn)一步深化醫(yī)藥衛(wèi)生體制改革，探索醫(yī)改這一世界性難題的中國式解決辦法2016年8月19-20日，全國衛(wèi)生與健康大會在京召開黨中央、國務(wù)院高度重視在探索世界性難題的中國式解決辦法進(jìn)程中邁出堅實步伐打好基礎(chǔ)提升質(zhì)量形成框架制度建設(shè)單項突破系統(tǒng)集成綜合推進(jìn)分級診療制度全民醫(yī)保制度綜合監(jiān)管制度藥品供應(yīng)保障制度現(xiàn)代醫(yī)院管理制度5項基本醫(yī)療衛(wèi)生制度5項基本醫(yī)療衛(wèi)生制度-建立科學(xué)合理的分級診療制度提升基層醫(yī)療衛(wèi)生服務(wù)能力引導(dǎo)公立醫(yī)院參與分級診療健全完善醫(yī)療衛(wèi)生服務(wù)體系推進(jìn)形成診療-康復(fù)-長期護(hù)理連續(xù)服務(wù)模式科學(xué)合理引導(dǎo)群眾就醫(yī)需求完善公立醫(yī)院管理體制建立規(guī)范高效的運行機(jī)制建立符合醫(yī)療衛(wèi)生行業(yè)特點的編制人事和薪酬制度建立以質(zhì)量為核心、公益性為導(dǎo)向的醫(yī)院考評機(jī)制控制公立醫(yī)院醫(yī)療費用不合理增長5項基本醫(yī)療衛(wèi)生制度-建立科學(xué)有效的現(xiàn)代醫(yī)院管理制度5項基本醫(yī)療衛(wèi)生制度-建