State extractive capacity, policy orientation, and inequity in the fi nancing and delivery of health care in urban China

Abstract

改革以后， 中国政府在承担卫生保健职能方面的意愿和能力发生了变化， 本文考察了这些变化对城镇卫生保健筹资和服务公平性的影响。文章着重分析了两个相关问题：在多大程度上， 卫生保健的筹资具有累进性？在多大程度上， 医疗服务的利用是公平的？第一节解释为什么在改革开放期间中国政府承担卫生保健的意愿与能力都有所下降， 并探讨这些变化对卫生总费用的结构产生了什么样的影响。接下来的两节分别对中国城市卫生保健筹资和服务利用的不平等程度进行了实证分析。第四节进一步指出， 筹资与服务方面的不平等将本来就处于弱势的社会群体置于更加不利的地位。总之， 以市场为导向的卫生体制改革不但没有解决医疗费用上涨问题， 反而加剧了这一问题；它因此损害了卫生保健筹资的公平性， 降低了弱势人群对卫生服务的获取， 增加了因病致贫的几率。 This paper explores how the Chinese government's reluctance/inability to invest in health has influenced the performance of its health system in the context of urban China. It focuses on two related issues. To what extent is the fi nancing of the health care system progressive? To what extent is the utilization of health care services equitable? Section I explains why the Chinese government has become less willing and able to bear the burden of health care during the era of economic reform and inspects the impacts of these changes on the structure of overall health expenditure. The following two sections empirically examine the extent to which the shift toward out‐of‐pocket spending has made health care less accessible and less affordable for the poor and vulnerable. Section IV explores how inequity in health care and health services has put groups of people who are already socially disadvantaged at more disadvantaged positions. The study fi nds that the market‐oriented health reform in urban China has exacerbated the cost problem that it intended to solve, reduced access to health services for the most vulnerable, and increased the instances of illness‐induced poverty.