搜索
21TextbookSeriesfor21stCentury()(CIP)./,.:,2001ISBN7-5045-3370-X............---.H31CIP(2001)090390(1:100029):*7871092169.25158200221200221:():28.00:13.00:64929211:64911190:()1998,,,,,,(),,,21,,,,,,,,;,,:()(),,,,,,200195CONTENTSUNIT1MethodsofHealthCareFinancing(1)UNIT2TheKeyConceptsofProviderPaymentMechanisms(13)UNIT3MethodsandMethodologicalIssuesinNationalHealthExpenditureEstimates(21)UNIT4HealthCarePolicyObjectives(27)UNIT5KeyObjectivesofHealthCareFinancingPolicy(PartA)(37)UNIT6KeyObjectivesofHealthCareFinancingPolicy(PartB)(47)UNIT7RegulationwithRegardtoEfficiencyofSocialHealthInsuranceSystem(55)UNIT8EquityintheDeliveryandFinancingofHealthCare(63)UNIT9Cost_effectivenessAnalysisinHealthCare:FirstPrinciples(73)UNIT10DifficultiesinHealthSectorReform(81)UNIT11HealthCostsandHealthInsuranceinCanada(89)UNIT12ResultsoftheOregonHealthPlan(96)UNIT13HealthCostsandFundinginAustralia(103)UNIT14FinancingtheNationalHealthServiceinEnglandinthe1980s(111)UNIT15HealthCostsandHealthInsuranceintheUnitedStatesinthe1980s(119)UNIT16HealthInsuranceandHealthCostsinJapaninthe1980s(126)UNIT17HealthInsuranceinGermany(134)UNIT1TEXTMethodsofHealthCareFinancingThereareseveralmethodsoffinancinghealthcare,eachofwhichhasitsownstrengthsandweaknesses.Thisunitpresentsvariousmethodsoffinancing.Themajormethodsoffinancingare:governmentrevenue,socialandprivatein-surance,userfees,andcommunityfinancing.Variousorganizationsofhealthcarede-liveryareusuallycombinedwithsomefinancingmethods.GovernmentFinancingGovernmentfinancingcantakeanumberofforms:generaltaxrevenuesanddeficitfinancing,theuseofinflation,earmarkedtaxes,governmentsponsoredlotter-iesandbetting,etc..Thethreemainformsofgovernmentfinancingaregeneraltax,inflation,andearmarkedtax.GeneralTaxGeneraltaxrevenueshavelongbeenusedineverycountryoftheworldtofinancecertaincomponentsofhealthcare,andusuallytheyarethemostimportantsourceoffinancing,althoughtheirdegreeofimportancevariessignificantly.Thelargestcomponentofgeneraltaxrevenuesinlow_incomecountriesisdutiesonimportsandexports.Thesecondmostimportantsourceoftaxrevenueindevelop-ingcountriesistaxesonbusinesstransactionsandprofits,whichyieldmorerevenuesthanpersonalincometaxes,thethirdmostimportantsource.Generaltaxrevenuesmaynotbeastablesourceoffinanceforhealthcare.Thisislargelytheresultoffactorssuchasthelowpoliticalpriorityfrequentlygiventothehealthcareinnationalbudgetdecisions;theinstabilityofdevelopingcountriesecono-my;thefrequentuseofpublicexpenditureasamacro_economicpolicy.1Inpractice,politicsplaysasignificantroleinallocatinggeneraltaxrevenuestothehealthsectorandamongdifferentprogramswithinthehealthsector.Thedistri-butionofpoweroftenfavorshigh_andmiddle_incomeresidentsintheurbanareas.Theresultingpolitically_determinedallocationoftaxfundsamongprogramsoftenreducesratherthanenhancestheequityofhealthcaredelivery.Generaltaxrevenuesmaybesupplementedbyborrowingandspendingfundsinthepresentandrepayingthemoversomeperiodoftime.Deficitfinancemayberaisednationallyorinternationally,throughmechanismssuchastheissuingofbonds,cer-tificatesorlong_termlow_interestloans.Whenitisused,deficitfinancingistypicallyforspecificconstructionorprograms.Unlesssuchprojectscontributedirectlytoin-creasedoutputwhichcanbetaxedtoservethedebt,thedeficitmustberepaidfromgeneraltaxrevenues.Therefore,inlow_andmiddle_incomecountries,highinflationratesandlackofconfidenceinthegovernmentsabilitiestohonoreventualredemptionofthebondmaymakeitdifficulttoutilizedeficitfinancingasasourceofsupportforhealthcare.InflationInflationmayalsobeemployedasanalternativemeansoffinancinghealthser-vices.Whengovernmentsspendmorethantheirrevenues,theymayfinancethisdeficitbyprintingmoremoney.However,withoutasimultaneousexpansioninout-put,theincreasedvolumeofmoneyleadstopriceincreaseinordertobidresourcesawayfromexistingusers.Itsmajorproblemisthattheburdenishighlyuneven,fallingmostheavilyontheelderwithfixedincomesandthosewithinflexiblewages.Moreover,manycountrieslacktheabilitytokeepinflationundercontrol,resultinginhyperinflationwithseriousconsequencesforeconomicgrowth,savingsandinvest-ment.EarmarkedTaxSomegovernmentmayearmarkaparticulartaxforhealthpurposes.Forex-ample,taxesonthesaleofparticularproductsmaybeearmarkedforhealthservicesateithernationallevelorwithinaparticularlocalgovernmentarea.Theproblemwithsuchsalestaxesisthattheyareoftendifficulttoadminister,maybepoliticallyunpop-ular,andareregressive(fallingproportionallymoreonlow_incomefamilies)if,asis2oftenthecase,taxesareleviedonitemssuchasalcohol,tobaccoorrecreationalevents.Anadvantageofthissourceoffinancingisthatitisimpossibletoassignataxtofundcertainpriorityprograms.Abel_Smith(1985)observesthatitmightbeprac-ticaltoearmarkforhealththetaxrevenuesoncertaingoodsandactivitiesthatmayhaveadversehealthimplications(e.g.alcohol,tobacco,cars,etc.).InsuranceInsuranceisusedbymostmiddle_andhigh_incomenationstofinanceasignificantportionoftheirnationshealthexpenditures.Insuranceservestwoprincipalfunctionsinimprovingtheeconomicwelfareofanation.First,insur