医改方案英文版（推荐8篇）
关于深化医药卫生体制改革的意见
参考译文
Opinions of the CPC Central Committee and the State Council on Deepening the
Health Care System Reform
In the spirit of the 17th CPC National Congress, for the purpose of establishing a health care system with Chinese characteristics, of gradually realizing the goal that everyone is entitled to basic health care services, and of raising the health level of the Chinese people, we hereby put forward the following opinions on deepening the health care system reform.I.Fully recognizing the importance, urgency and arduousness of deepening the health care system reform
The health care sector is a major livelihood issue, as it is closely related to the health of billions of people and the happiness of every household.To deepen the health care system reform, quicken the development of health care sector, meet the people’s ever increasing health care demands, and continuously improve the people’s health is an inevitable requirement of implementing the Scientific Outlook on Development and accelerating economic and social development in a coordinated and sustainable manner, an important measure to maintain social fairness and justice and improve the quality of people’s life, and also a major task of building moderately prosperous society in an all-round way and constructing harmonious socialist society.Since the founding of the People’s Republic of China in 1949, and since the beginning of the reform and opening-up in particular, China’s health care sector has made remarkable achievements.A health service system covering both urban and rural residents has basically come into being;the disease prevention and treatment capacity has been continuously strengthened;the population covered by health care has gradually expanded;health science and technology level has rapidly risen;the people’s health level has been markedly improved;and the major resident health indexes now rank among the highest in the developing countries.Since the major victory won in combating SARS in particular, governments at various levels have increased their investment, the development of public health, rural health care and urban community health care has been accelerated, and the New Rural Cooperative Medical Scheme and the basic medical insurance system for urban residents have made breakthroughs, all of which have laid a solid foundation for deepening the health care system reform.At the same time, however, we must be aware that there is still a rather prominent contradiction between the current development level of China’s health care sector and the people’s health demands and the requirements of balanced socio-economic development.Health care undertakings are developing unevenly between urban and rural areas and among different regions;resource allocation is unreasonable;the work of public health as well as rural and community health care is comparatively weak;the medical insurance system is incomplete;pharmaceutical production and circulation order is not well regulated;the hospital managerial system and operational mechanism are imperfect;government investment in health is insufficient;medical costs are soaring, individual burden is too heavy, and therefore, the people’s reaction is very strong.Featuring arduous health care tasks, the period from now to 2020 is crucial for China to build moderately prosperous society in an all-round way.Along with economic development and improvement of people’s living standards, the people will make higher demands on bettering health care services.Industrialization, urbanization, population aging, disease spectrum change, eco-environmental change and other factors pose a series of new and serious challenges to the health care work.To deepen the health care system reform is a strategic choice to accelerate the development of health care undertakings, an important channel to realize the goal of enabling people to share the achievements of reform and development, and an urgent aspiration of the broad masses of the people.Deepening the health care system reform is a difficult social systemic project involving broad aspects.China has a large population, low per capita income, significant urban-rural and regional disparities, and will be at the primary stage of socialism for a long period of time.These basic national conditions determine that the task of deepening the health care system reform is extremely complicated and arduous, and that it will be a gradual process.Therefore, only through long and arduous endeavors and perseverant explorations on the basis of specified directions and framework can we progressively establish a health care system in line with the country’s actual national conditions.To ensure the reform proceed smoothly and reach the expected goals, not only the reform should be pushed forward with firm determination, but also the work be well organized and steadily implemented.II.The guidelines, basic principles and overall goal of deepening the health care system reform
(i)The guidelines for deepening the health care system reform It should be guided by the important thoughts of Deng Xiaoping theory and Three Represents;it should implement in depth the Scientific Outlook on Development;it should proceed from China’s national conditions, and draw on the useful international experience;it should aim at achieving the goal of ensuring basic health care services for everyone, and emphatically address the problems concerning the most direct and real interests of the people or the ones that the people are most concerned about.It should adhere to the commonweal nature of public health care;it should adhere to the policy of regarding prevention as the main task and the rural areas as the focal point, and of laying equal stress on traditional Chinese medicine(TCM)and western medicine;it should implement separation between government agencies and public institutions, between government administration and business operations, between medical and pharmaceutical services, and between profit and non-profit;it should strengthen government responsibility and investment, improve national health policies, perfect institutional systems, enhance supervision and regulation, promote institutional innovations, and encourage social participation, so as to construct a basic health care system covering urban and rural residents, continuously raise the health level of the entire population, and promote social harmony.(ii)The principles for deepening the health care system reform The health care system reform must be firmly based on the country’s basic conditions and proceed from reality, adhere to the right reform principles.-We should adhere to the people-first principle and attach primary importance to safeguarding the rights and interests of the people’s health.We should adhere to the tenet of serving the people’s health with health care undertakings;regard safeguarding the people’s health as the center, and take the entitlement of basic health care services to everyone as the fundamental aim and outcome;make sure that the principle of commonweal nature be complied with throughout the entire process, from designing the reform program, establishing the health system, to constructing the health care service system;ensure that the basic health care system be public goods provided to the entire population;emphatically resolve the prominent problems to which people strongly react, and strive to achieve the goal of ensuring that health care services be available to the entire population.-We should adhere to finding a foothold in China’s national conditions and build the health care system with Chinese characteristics.We should adhere to proceeding from the country’s basic conditions, sum up the practical experience of the reform and development of China’s health care undertakings by seeking truth from facts, and accurately identify the law of development and principal challenges of health care undertakings;adhere to ensuring that the basic health care service level is in coordination with the socio-economic development, and in conjunction with the affordability of the people;bring the role of TCM(including ethnic minority traditional medicine)into full play;adhere to positioning on local conditions, specifying guidance for different localities, giving full play to local initiatives, and exploring with the aim to establishing the basic health care system conforming to the country’s national conditions.-We should adhere to the unity of fairness and efficiency and combine government’s leading role with the role of market forces.We should intensify government’s responsibility in the basic health care system, strengthen governmental functions in institutionalization, planning, fund-raising, service provision, supervision and regulation, etc., safeguard the commonweal nature of public health care system, and advance fairness and justice.In addition, we should emphatically give full play to the role of market forces, call on social participation, promote the formation of orderly competition mechanism, upgrade operational efficiency, service level and quality of the health care system, and satisfy the people’s multi-layer and diversified demands for health care services.-We should adhere to overall planning and all-round consideration and combine resolving currently prominent problems with improving the institutional system.We should proceed from taking the overall situation into consideration, balance urban and rural development and development among different regions, reconcile the interests of the supplier, the customer and other stakeholders, emphasize the combination of prevention, treatment and rehabilitation, and appropriately handle the relationship among government, health care institutions, pharmaceutical enterprises, health care workers and the people.We should be far-sighted and engage in institutional innovations on the one hand, and focus on current situation and emphatically tackle the prominent problems of the health care system on the other hand;We should pay adequate attention to the overall design, clarify the overall reform direction, objective and basic framework on the one hand, and highlight the key points, conduct step-by-step implementation, and actively and prudently press ahead with the reform on the other hand.(iii)The overall goal of deepening the health care system Establish and improve the basic health care system covering urban and rural residents, and provide the people with secure, efficient, convenient and affordable health care services.By 2011, the basic medical security system shall have completely covered urban and rural residents, the essential medicines system shall have been preliminarily established, urban and rural grass-roots health care service system shall have been further strengthened, the basic public health services shall have been available far and wide, pilot projects for reforming state-owned hospitals shall have made breakthroughs, the accessibility to the basic health care services shall have been improved markedly, residents’ burden of medical costs shall be effectively reduced, and the problem of “difficult and costly access to health care services” shall have been remarkably relieved.By 2020, the basic health care system covering urban and rural residents shall have been fundamentally established.We shall have set up, across the country, a fairly complete public health service system and health care service system, a comparatively sound medical security system, a secured and relatively well regulated pharmaceutical supply system, a comparatively sound health care institution management and operational system, a multi-sponsored medical configuration shall be formed, everyone shall have access to the basic health care services, the multi-layer demands of the people for health care services shall be met preliminarily, and the health level of the people shall be further enhanced.III.Improving four major health care systems and establishing the basic health care system covering urban and rural residents
Four systems covering urban and rural residents shall be established, including the public health service system, health care service system, medical security system, and a secured pharmaceutical supply system, with an aim to forming a “four in one” basic health care system.The four systems shall be constructed in conjunction with each other, supplement each other and develop in a coordinated way.(iv)Strengthening the construction of the public health service system in an all-round way Efforts should be made to establish and improve professional public health service networks, which include diseases prevention and control, health education, maternity and child care, mental health, emergency treatment, blood collection and supply, hygiene supervision, family planning, and etc.;improve the public health service functions of the basic health care service system, which is based on grass-roots health care service network;establish a public health service system featuring a clear-cut division of work, information-exchanging, resource-sharing, coordination and interaction;improve the capacity to deal with public health service and public health emergencies, and make equalized basic public health services gradually available to urban and rural residents.Efforts should be made to identify the scope of public health services.Clarify the national basic public health service items, and increase step by step the service contents.Encourage the local governments to increase, in accordance with the local economic development level and prominent public health problems, their public health service contents on the basis of the service items defined by the central government.Efforts should be made to improve the public health service system.Further clarify the functions, goal and tasks of the public health service system, optimize personnel and equipment configurations, and explore the effective means of integrating public health service resources.Perfect the major diseases prevention and control system as well as public health emergency mechanism, strengthen the surveillance, prevention and control of the diseases that severely threatening the people’s health, such as infectious diseases, chronic diseases, endemic diseases, occupational diseases, birth defects, and so on.And strengthen the construction of urban and rural first-aid system.Efforts should be made to strengthen health promotion and education.Health care institutions, government agencies, schools, communities, enterprises, etc.shall massively carry out health education, take full advantage of various media, strengthen the dissemination of medical and health knowledge, advocate healthy and civilized lifestyle, promote rational nutrition among the public, and enhance the health awareness and self-care ability of the people.Efforts should be made to implement in depth the patriotic public health campaign.Integrate the rural environmental sanitation and environmental pollution treatment into the new socialist rural construction plan, promote the construction of “Hygienic Cities and Civilized Villages and Towns”, and continuously improve the environmental sanitation of life and work of urban and rural residents.Efforts should be made to strengthen hygiene supervision services.Intensively promote environmental sanitation, food hygiene, occupational health, school health as well as the health services for floating population, such as migrant workers, etc.(v)Further improving the health care service system A rationally structured health care service system covering urban and rural residents should be established by adhering to the operational principle of taking the non-profit health care institutions as the main body, for-profit health care institutions as the supplement, with the state-owned institutions playing a leading role, while non-state-owned health care institutions making synergies in the development.Efforts should be made to energetically develop the rural health care service system.Efforts should be made to further complete the rural health care service network with county-level hospitals as the bellwether, township health centers and village clinics as the basis.As the intra-county health care center, the county-level hospitals shall be mainly in charge of the basic health care services, treating and saving patients with severe or acute diseases, as well as take the responsibility of providing professional and technical guidance to township health centers and village clinics and offering further education and training to the health care workers of two latter institutions.The township health centers shall take the responsibility of providing public health services and comprehensive services of diagnosing and treating the commonly or frequently encountered diseases, and of offering professional management over and technical guidance to village clinics, which shall, in turn, take the responsibility of the administrative villages’ public health services, the diagnoses and treatment of general diseases and other services.An integrated approach shall be adopted to manage both the township health centers and village clinics in the rural areas where conditions permit.Efforts should be made to actively promote the construction of rural health care infrastructure and capacity building.The government shall focus on the well-running of the county-level hospitals and a health center in each town, support the construction of village clinics through various ways, and ensure that each administrative village have a clinic, so as to vigorously improve rural health care conditions and upgrade service quality.Efforts should be made to improve the new urban health care service system on the basis of community health care services.Quicken the building of the urban community health care service network with community health centers as the main body, and improve service functions.With safeguarding the community residents’ health as the focal point, provide them with public health services such as diseases prevention and control, preliminary diagnoses and treatment of the general, commonly and frequently encountered diseases, chronic diseases management and rehabilitation services.Transform the community health care service mode, continuously raise the service level, take the initiative to offer services, provide household visits, and gradually assume the responsibility and duties of the “gate-keeper” for residents’ health.Efforts should be made to complete the functions and responsibilities of various hospitals.Efforts should be made to optimize the configuration and structure, give full play to the backbone role of urban hospitals in terms of diagnoses and treatment of dangerous, severe and acute diseases as well as difficult and complicated diseases, medical education, research, guiding and training grass-roots health care workers, and etc.Conditions permitting, major hospitals may, in light of demands of the regional health planning, promote the rational flowing of health care resources through means of trusteeship, reorganization, and etc.Efforts should be made to establish the mechanism of labor division and work coordination between urban hospitals and community health service institutions.Urban hospitals shall, through technical support, personnel training and other ways, lead the sustainable development of community health services.Meanwhile, urban hospitals shall take such comprehensive measures as strengthening service capacity, reducing fees and charges, raising reimbursement ratio and etc.to guide general diagnosis and treatment down to grass-roots medical institutions, and gradually achieve the goal of the initial diagnosis to be conducted in community health centers, classification of medical treatments, and dual referral.Efforts should be made to integrate urban health resources, make full use of existing sources, such as primary and secondary urban hospitals, health care institutions affiliated to state-owned enterprises and public institutions and other privately-run medical institutions, and develop and improve the community health service network.Efforts should be made to bring into full play the role of TCM(including ethnic minority traditional medicine)in the prevention and control of diseases, public health emergency response, as well as in health care services.Reinforce the construction of TCM clinical research bases and TCM hospitals, organize and carry out the joint research of preventing and treating difficult and complicated diseases with TCM.Vigorously promote appropriate TCM techniques in grass-roots health care services.Take up favorable policies to foster TCM development, and promote the inheritance and innovations of TCM.Efforts should be made to establish the system of urban hospitals offering counterpart support to rural health care.The developed regions shall reinforce their counterpart support to the development of health care undertakings in the poverty-stricken regions and ethnic minority regions.Major urban hospitals shall establish long-term stable counterpart support to and cooperation with county-level hospitals, assisting the latter to improve health care level and service capacity through clinical practice, staff training, technical guidance, equipment support and other ways.(vi)Quickening the construction of the medical security system Efforts should be made to quicken the construction and improvement of the multi-layer medical security system covering urban and rural residents, with the basic medical security as the main body, and other diversified supplemental medical insurance and commercial health insurance as the supplement.Efforts should be made to establish the basic medical security system covering urban and rural residents.The basic medical security system shall be jointly composed of urban employees’ basic medical insurance, urban residents’ basic medical insurance, New Rural Cooperative Medical Scheme and urban-rural medical assistance system, covering urban employees, urban non-employees, rural population, and urban and rural economically strained residents, respectively.Efforts should be made to adhere to the principle of covering a wide coverage, ensuring basic medical services and pursuing sustainable development, proceed from emphatically ensuring the treatment of major diseases, gradually extend to the ailments for clinics, and continuously raise the medical security level.Efforts should be made to establish a multi-channel fund-raising mechanism featuring a clear-cut division of responsibility of the government, employer, family and individual, and rational expense-sharing proportions, so as to achieve social mutual-aid.Along with economic and social development, efforts should be made to uplift the fund raising and pooling levels step by step, narrow the gap between different insurance schemes, and eventually achieve the fundamental unity of those schemes.Efforts should be made to further complete urban employees’ basic medical insurance system, quicken the coverage of the employed population, emphatically address basic medical insurance problems of employees and retirees of the closed-down or bankrupted state-owned enterprises and enterprises with financial difficulties, employees of non-public economic sectors as well as temporary contract workers;fully implement the urban resident basic medical insurance in 2009, and lay stress on tackling basic medical insurance problems concerning the aged, the disabled and the children;fully implement the New Rural Cooperative Medical Scheme, progressively raise the government subsidy level, and appropriately increase the farmers’ contributions, so as to enhance the medical security capacity;upgrade the urban and rural medical assistance system, subsidize those who are economically strained for the premium payment，and subsidize them for their unbearable medical expenses, by this way to build a firm medical security baseline.And efforts should be made to explore the establishment of management mechanism for an integrated urban and rural basic medical security system.Efforts should be made to encourage trade unions and other social groups to carry out diversified mutual aid activities for health care, and encourage and guide various organizations and individuals to develop charity medical assistance.Efforts should be made to properly link the urban employees’ basic medical insurance system, urban residents’ basic medical insurance system, New Rural Cooperative Medical Scheme and urban and rural medical assistance system.Efforts should be made to actively and properly conduct the transferal and continuation of basic medical insurance credentials from one region to another, laying stress on the migrant workers floating between urban and rural areas;improve the settlement services for treatment received allopatry, focusing attention on the retirees settled in places other than the locality where they used to work;properly address basic medical insurance issues concerning migrant workers;in light of government regulations, clarify the contribution obligations of enterprises with whom migrant workers sign employment contracts and establish steady labor relationship, and such migrant workers shall be integrated into urban employees’ basic medical insurance system;other migrant workers may participate, in accordance with their actual situation, in the New Rural Cooperative Medical Scheme of the places of their origin, or the urban residents’ basic medical insurance of their work locations.Efforts should be made to actively develop commercial health insurance.Encourage commercial insurance agencies to develop health insurance products to meet different demands, simplify claim formalities, provide convenience to the people, and satisfy diversified health demands.Encourage enterprises and individuals to resolve their demands beyond the basic medical insurance through participating in commercial insurance and diversified supplemental insurance.On the premise ensuring fund security and effective supervision, actively advocate, in the form of government purchase of medical security services, to explore the possibility of entrusting qualified commercial insurance agencies with handling various medical security management services.(vii)Establishing and completing a secured pharmaceutical supply system Efforts should be made to accelerate the establishment of a secured pharmaceutical supply system on the basis of the national essential medicines system, and ensure medicine safety for the people.Efforts should be made to establish the national essential medicines system.The central government shall unitarily formulate and issue national essential medicines list, and rationally determine the categories and quantities of medicines in line with China’s medication characteristics and with reference to international experience;in this process, the following principle shall be adhered to, i.e., medicines selected must be necessary for disease prevention and treatment, must be safe and effective, must be of reasonable price, must be convenient to use, and equal stress must be laid upon TCM and western medicines.Efforts should be made to establish a secured production and supply system of essential medicines, and bring market forces into full play under government macro-control;open tender and unified distribution shall be adopted for the essential medicines procurement, and the intermediary links shall be reduced, so as to ensure the people’s access to the essential medicines.The central government shall set government-guided retail prices for the essential medicines, within which, the provincial people’s government shall determine unified purchasing prices of its own region according to its actual situation of tender invitation.Efforts should be made to regulate the use of the essential medicines, and formulate the essential medicines clinical application guide and formulary.All urban and rural grass-roots health care institutions shall be equipped with and use the essential medicines for medication, and other various health care institutions shall also take the essential medicines as their primary choice remedy, and ascertain the due application proportions.All essential medicines shall be integrated into the reimbursement list of basic medical insurance, with markedly higher reimbursement proportions than those of non-essential medicines.Efforts should be made to regulate pharmaceutical production and circulation.Efforts should be made to improve development policies and programs for the pharmaceutical industry, enforce rigorous market access and drug registration and approval, vigorously regulate and consolidate the production and circulation order, promote independent innovation capacity of pharmaceutical enterprises and optimize and upgrade the structure of the pharmaceutical industry, develop modern drug logistics and chain-store operations, and promote the integration of drug production and circulation enterprises.Efforts should be made to establish the rural drug supply network offering more convenience to the people and more benefit to farmers;improve the drug reserve system;support the production of small-quantity special medication and first-aid medicines;regulate medicine procurement and resolutely crack down on commercial bribery in pharmaceutical procurement and sales;strengthen the surveillance of drug adverse reaction and establish early warning and emergency response mechanism for drug safety.IV.Improving institutional mechanism, ensuring effective and well regulated operations of the health care system
Efforts should be made to improve the health institutional mechanisms, involving management, operation, investment, price and supervision, reinforce the development of science, technology, professional talents, information and legal system, and ensure that the health care system shall operate in an effective and well regulated way.(viii)Establishing a coordinated and unified health care administration system Efforts should be made to implement localization and sector-wide administration.Each health care institution, regardless of their ownership, investor, administrative affiliation, business operation category, shall be subject to the unified planning, access and regulation implemented by the health administrative department in the location concerned.The central and provincial governments may establish limited number of medical centers or regional centers undertaking medical research and teaching functions, as well as specialized hospitals undertaking the diagnoses and treatment of the difficult and complicated diseases across the country or a region.County(city)governments shall mainly take the responsibility of establishing county-level hospitals, village and community health service institutions;and other public hospitals shall be established by the cities.Efforts should be made to strengthen regional health planning.Provincial governments shall formulate allocation criteria for health resources, organize the formulation of regional health planning and plans for setting up health care institutions, and define the quantity, scale, layout and functions of health care institutions.Efforts should be made to rationally formulate the construction and equipment configuration standards for township health centers(village clinics), community health centers(stations)and other grass-roots health care institutions and hospitals at various levels.Efforts should be made to make full use of and optimize the distribution of existing health care resources, gradually integrate and consolidate health care institutions that are inconsistent with requirements of relevant plans, strictly control the deployment of large-sized medical equipment, encourage joint construction and sharing, and enhance the utilization efficiency of medical and health resources.The newly added health resources must be in conformity with regional health planning, and priority should be given to weak areas such as rural and community health services.Efforts should be made to strengthen the connection between regional health planning and urban-rural development plans, land use overall plans and etc;establish the monitoring and assessment mechanism for regional health planning and resource allocation.Efforts should be made to promote the reform on the administration system for public hospitals.The reform shall be conducive to reinforcing of the commonweal nature of public hospitals and the effectiveness of government regulation, and actively explore diversified forms for effectively realizing the separation of functions of government agencies and public institutions, and separation of administration and business operations.Efforts should be made to further transform government functions, with health administrative departments mainly taking the responsibility of sector administration functions, such as health development planning, review of qualification and access, formulation of rules and standards, supervision and regulation on services, and etc., and other departments concerned, each according to their own functions, conducting administration and providing services.Efforts should be made to put into effect the independent corporate status of public hospitals.Efforts should be made to further improve the basic medical insurance management system.The central government shall unitarily formulate the framework and policies of the basic medical insurance system, while local governments shall take the responsibility of organizing the implementation and management, create conditions for gradually uplifting the level of fund-pooling.Efforts should be made to effectively integrate the resources handling the basic medical insurance, and progressively achieve unified administration of urban and rural basic medical insurance.(ix)Establishing an efficient and well regulated operation system for health care institutions All expenditures and revenues of public health institutions shall be integrated into budget management.In light of the duties and tasks of the said institutions, the government shall rationally determine their staff size, salary level, and budget scale, clarify the duties of various positions, exercise rigorous staff enrolment criteria, strengthen performance assessment, establish the staff placement system on the basis of competitive selection, and improve work efficiency and service quality.Efforts should be made to transform the operation mechanism of grass-roots health care institutions.As for the government-sponsored grass-roots health care institutions, such as urban health service centers(stations)and township health centers, their service functions shall be strictly defined, and the use of appropriate techniques, equipment and essential medicines be clearly required;and the said institutions shall provide the people with low-cost services, and maintain their commonweal nature.Efforts should be made to strictly verify the staff size, implement personnel employment system, and establish the human resources management system featuring competitiveness, motivation and efficiency;clarify the scope and standard of expenditure and income, implement financial management measures, including task verification, expenditure and revenue verification, performance assessment and subsidy;explore the possibility of implementing diversified effective management methods, such as separate management of expenditure and revenue, prepayment of the total amount of public health and basic medical insurance funds, exercise strict management of expenditure and revenue budgeting, and increase the funds utilization efficiency;reform the drug margin policy and implement drug sale with no markup;strengthen and improve internal management, establish an evaluation and incentive system with service quality as the core, and post responsibility and performance as the basis, and form a long-term mechanism ensuring fairness and efficiency.Efforts should be made to establish a well regulated operational mechanism of public hospitals, which shall comply with the principle of commonweal nature and social benefits, adopt a patient-oriented approach, optimize service process, and regulate medication, examination and treatment.Efforts should be made to deepen the operation mechanism reform, establish and better the hospital corporate governance structure, specify rights and responsibilities of owners and managers, and form a mechanism featuring check and balance of policy-making, implementation and supervision, and integrating responsibility, incentives, restraints, competitiveness and vitality.Efforts should be made to promote the separation between health care services and drug sale, and actively explore diversified effective ways to gradually reform the mechanism of compensating the medical cost through drug sale;gradually reform or rescind the drug margin policy through implementing differentiated price markup between drug purchase and sale and through setting up prescription service fees;meanwhile, improve the compensation mechanism of public hospitals through appropriately adjusting health care service prices, increasing government investment, reforming methods of payment, and etc.Efforts should be made to further improve the financial and accounting management system, implement rigorous budget management, and strengthen financial regulation and operation supervision.Local governments may, in line with local circumstances, conduct pilot projects of diversified management methods in hospitals where conditions permit, for instance, methods such as “expenditure and revenue verification, compensating expenditure with revenue, turning in the surplus, subsidy for the gap, clear-cut reward and penalty”.Efforts should be made to reform the human resources system, improve income distribution and incentives, promote the employment system and post management system, enforce rigorous management on total salary, implement the system of comprehensive performance evaluation and post-performance based salary in line with service quality and workload, and effectively mobilize the initiatives of health care workers.Efforts should be made to construct a sound operation system for institutions handling medical insurance, including completing the internal governance structure, establishing a reasonable staff placement mechanism and a fair distribution system, improving the incentive and restraint mechanism, and enhancing the handling capacity and management efficiency of medical insurance.(x)Working out a multi-source health investment mechanism with the government playing the dominant role Efforts should be made to specify the health investment responsibility of the government, society and individuals;establish the dominant position of the government in providing public health and basic health care services.The public health services shall be mainly provided, through government funding, to urban and rural residents in an equalized way.The expenses of the basic health care services shall be rationally proportioned and borne among the government, society and individuals.And special health care shall be directly paid for by individuals or borne by commercial health insurance.Efforts should be made to construct and improve the government health investment mechanism.Both the central and local governments shall increase their health investment, and reconcile the needs of both the supplier and the recipient.Gradually raise the proportion of government investment in the total health expenditure, and effectively alleviate individual residents’ burden in terms of basic health care expenses;the growth rate of government health investment shall be higher than that of the current financial expenditure, so as to gradually increase the proportion of government health investment in the current financial expenditures.The newly added government investment shall be emphatically used in supporting public health, rural health, urban community health and basic medical security.In light of the principle of burden-sharing at all government levels, efforts should be made to rationally divide the health investment responsibility among the central government and local governments at various levels.The local governments shall take the principal responsibility, while the central government shall mainly subsidize national immunization program, interregional prevention and control of major communicable diseases and other issues of public health, basic medical security of urban and rural residents as well as the development of relevant public-owned health care institutions.And efforts should be made to increase special transfer payments by the central and provincial governments to financially constrained regions.Efforts should be made to improve the mechanism of government investment in public health.Regarding specialized public health service institutions, the funding for their staff, development, construction and operations shall be appropriated in full amount by the government, and the legitimate service income of the said institutions shall be turned over to be kept in a special fiscal account or integrated into budget management.Gradually increase the average per capita public health funding, and complete a secured mechanism for public health service funding.Efforts should be made to improve the mechanism for government investment in urban and rural grass-roots health care institutions.The government takes the responsibility of providing funding for the basic construction, equipment purchasing and staffing for the government-sponsored township health centers, urban community health centers(stations), as well as the operational funds for offering public health services so that the said institutions can fully function.As to all the township health centers and urban community health service institutions sponsored by various non-public sponsors, local authorities may set due government subsidies through ways such as purchasing services and etc.Efforts should be made to support the construction of village clinics, and grant reasonable subsidies to rural doctors who take the responsibility of fulfilling such tasks as public health services and etc.Efforts should be made to implement the policy of granting government subsidies to public hospitals.Gradually increase the government investment, which shall be mainly used for basic construction and equipment procurement, development of key subjects, funds for retirees in conformity with the state regulations concerned, and subsidies for policy-related losses, and be also used for granting special subsidies to government-sponsored tasks, such as public health services, etc.All these shall aim to a well-regulated and sound mechanism of government investment in public hospitals.In terms of investment policies, preference shall be given to TCM hospitals(including ethnic minority hospitals), gynecology and obstetrics hospitals, children’s hospitals, and hospitals specialized in prevention and treatment of communicable diseases, mental disorders, occupational diseases, and etc.Efforts should be made to strictly control the construction scope, standards and loan-taking of public hospitals.Efforts should be made to improve the mechanism of government investment in the basic medical security.The government shall appropriate necessary funds to support the development and improvement of the New Rural Cooperative Medical Scheme, urban residents’ basic medical insurance, urban employees’ basic medical insurance as well as urban and rural medical assistance system;guarantee normal funding of the relevant institutions handling the above tasks.Efforts should be made to encourage and guide social capital to sponsor health care undertakings.Actively promote the development of non-public health care institutions, and form a health care system with multiple categories of investors and diversified investment modes.Waste no time in working out and complete relevant policies and regulations, regulate the access conditions of social capital, including overseas capital, for sponsoring health care institutions, and complete sector-wide administration policies featuring fairness and justice.Encourage social capital to sponsor non-profit health care institutions in accordance with the law.The government shall work out guiding opinions on the system reform of public hospitals, and actively guide social capital to participate in the system reform and reorganization of some public hospitals, including the hospitals sponsored by state-owned enterprises.Steadily launch pilot projects in the system reform of public hospitals, appropriately reduce the proportion of public health care institutions, and form the configuration of public hospitals and non-public hospitals featuring mutual promotion and common development.Support the qualified personnel to start business in accordance with the law and provide people with convenient access to health care services.Improve the classified administration policy and preferential taxation policy for health care institutions.Strengthen, in accordance with the law, the regulation on the health care services sponsored by non-public investors.Efforts should be made to energetically develop medical charity undertakings.Work out relevant preferential policies to encourage non-public entities to sponsor charity health care institutions, or make charity donations to medical assistance and health care institutions, and etc.(xi)Establishing a sound health care pricing system Efforts should be made to regulate the management on health care service pricing.As to the basic health care services provided by non-profit health care institutions, the government-guided pricing shall be used, and the other services shall be priced independently by health care institutions.The central government shall take the responsibility of formulating pricing policies, items, pricing principles and methods for health care services;the provincial or municipal competent pricing departments shall verify, in conjunction with the health, human resources and social security departments, government-guided prices for basic health care services.The basic health care services shall be priced by deducting the service cost subsidized by government funding, so as to embody the reasonable cost and technical value of health care services.The services provided by health care institutions and doctors at different levels shall be priced at different grades.Efforts should be made to regulate the pricing items and standards of public health care institutions, and explore the reform on charging methods such as Diagnoses-Related Groups Payment;establish the system for price surveillance on medical device, supervision on and auditing of the service cost of medical examination and treatment and their regular pricing adjustment.Efforts should be made to reform the drug pricing mechanism.Rationally adjust the government pricing scope, improve the pricing methods, increase transparency, encourage enterprises to be engaged in independent innovations with the price leverage, and promote the production and utilization of national essential medicines.Gradually implement the pre-pricing economic evaluation system for new and patent drugs.Implement the low price system for generic drugs when it enters the market, so as to curb the low-level repeated construction.Strictly control the price difference ratio in pharmaceutical circulation.Carry out pilot projects, such as differentiated price markup on drugs sold in hospitals, prescription service fees and etc.to guide hospitals on rational medication.Strengthen the price control and management on medical consumables and the medical appliances used for implantation(intervention)during the circulation and utilization.Optimize the medical pricing surveillance system, and regulate independent pricing behavior of hospitals.Efforts should be made to actively explore and build the negotiation mechanism for medical insurance handling institutions, health care institutions and pharmaceutical suppliers, and bring into full play the restraining role of medical security over health care services and pharmaceutical expenditures.(xii)Establishing a rigorous and effective health care regulatory system Efforts should be made to reinforce the regulation on the health care system.Complete the health supervision and enforcement system, and enhance the capacity building of urban and rural health supervision institutions.Strengthen the regulation on health care service behavior and quality, improve the health care service standards and quality evaluation system, regulate the management system and work flows, quicken the formulation of the treatment protocols, and complete the health care service quality surveillance networks.Strengthen the regulation on the admittance and operation of health care institutions.Strengthen public health regulations, including drinking water safety, occupational hazards prevention, food security, medical waste disposal, etc.and rigorously crack down, in accordance with the law, the law-breaking behavior that jeopardizes the health and life safety of the people.Efforts should be made to improve medical security regulation.Strengthen the regulation on medical insurance handling, fund management and use, etc., establish the mechanism for effective utilization of medical insurance funds and risk prevention.Strengthen the monitoring role of medical security on health care services, improve payment system, actively explore the payment methods such as capitation, Diagnoses-Related Groups as well as prepayment of total amount, etc., and establish an effective restraining mechanism that lays equal stress on incentives and penalty.Strengthen the regulation on commercial health insurance and promote sound development.Efforts should be made to strengthen pharmaceutical regulation.Strengthen government regulation responsibility, improve the regulation system, and implement strict regulation on pharmaceutical research, production, circulation, utilization, pricing and advertisement.Implement regulated quality management of pharmaceutical production, and strengthen the regulation on the production of high-risk items.Strictly implement the regulations on pharmaceutical business operation and management, explore and put in place categorized and graded licensing for the administration of pharmaceutical operation, and reinforce the supervision and sampling inspection on key categories of drugs.Establish the rural drug supervision networks.Strengthen government regulation on drug pricing, and effectively inhibit bubble prices.Regulate the clinical utilization of drugs, and bring into full play certified pharmacists’ guidance on the rational medication and pharmaceutical quality management.Efforts should be made to establish the regulation system featuring open information and multiple-stakeholder participation.Encourage social organizations, such as trade unions and individuals to exercise independent appraisal and supervision on the performance of the competent government departments, health care institutions and the relevant systems.And strengthen self-discipline in the sector.(xiii)Establishing a sustainable development mechanism for scientific and technological innovation and a secured mechanism for professional talents in the health sector Efforts should be made to promote the scientific and technological progress of health care services.Treat health care technological innovation as a priority of national scientific and technological progress, strive to tackle difficult health care issues, and provide technological safeguard for the health of the people.Increase investment in medical research, deepen the health care system reform, integrate advantageous medical research resources, quicken the implementation of key projects of medical science and technology, encourage independent innovation, reinforce the research on prevention and treatment technology of major diseases and key technology of new medicine, and strive to make new breakthroughs in basic and applied medical research, hi-tech research, research on TCM, integration of TCM and western medicine, etc.Develop and produce medical appliances conforming to China’s national conditions.And extensively carry out international cooperation and exchanges on health science and technology.Efforts should be made to reinforce the development of professional health care talents.Work out and implement the development program for professionals, emphatically strengthen the training and cultivation of health care professionals and paramedic personnel in fields such as public health, rural health, urban community health, etc.Formulate preferential policies, encourage outstanding health talents to provide their services in rural areas, urban communities and the mid-western regions.Those health professionals, who have worked for a long period of time in urban and rural grass-roots health care institutions, shall be rendered appropriate preferential policies in terms of professional title promotion, professional training, compensation policy, etc.Complete the qualification system for general practitioners, complete the on-the-job training system for the health professionals working in both rural areas and urban communities, encourage the said personnel to receive academic education, promote the professional standardization for rural doctors, and realize as soon as possible the goal that all the grass-roots health care institutions are staffed with qualified general practitioners.Reinforce the development of high-level professionals in research, medical treatment, health management, etc.Establish the standardized training system for resident physicians, and intensify continued medical education.Reinforce the development of paramedic professionals, and gradually resolve the existing problem of the low proportion of paramedic personnel.Cultivate TCM professionals and expand the team.Steadily promote the rational flow of health care professionals, facilitate diversified ways of talent exchange among different health care institutions, and explore the feasibility of multiple-site practice of certified practitioners.Regulate the qualifications for hospital managerial personnel, and gradually form a professional and specialized managerial team for health care institutions.Efforts should be made to readjust the structure and scale of higher medical education.Strengthen education on general medicine, improve standardized and regulated clinical medical education, and enhance the quality of medical education.Increase investment in medical education, intensively develop undergraduate and non-degree medical college education, which should be geared to the needs of rural areas and urban communities, adopt diversified methods such as targeted free training to cultivate health care professionals for poverty-stricken rural areas, and foster a large number of qualified medical practitioners who are devoted to rural areas and ready to serve farmers.Efforts should be made to build sound and harmonious relations between health care workers and patients.Strengthen medical ethics, pay adequate attention to the humanitarian quality cultivation and professional caliber education of the health care workers, vigorously carry forward the spirit of “healing the wounded and rescuing the dying”.Optimize the work surroundings and conditions, safeguard the legitimate rights and interests of health care workers, and arouse their enthusiasm to better services and improve efficiency.Improve the medical practice insurance, carry out medical social work, complete the mechanism for handling medical disputes, and enhance the communications between practitioners and patients.Foster in the entire society a good atmosphere of respecting medical science, health care workers as well as patients.(xiv)Establishing practical and shared health care information system Efforts should be made to energetically promote health care informatization.Focusing on promoting the informatization of public health, health care services, medical insurance, drugs, financial regulation, etc., efforts should be made to integrate resources, strengthen the construction of information standardization and public service information platform, and gradually realize unified standards, high efficiency and interrelated communications.Efforts should be made to accelerate the construction of health care information system.Improve the public health information system with the disease control network as the mainstay, and enhance the capacity for forecast, early warning, analysis and reporting;take creating resident health archives as the priority, construct the rural and community information network platform;take hospital management and electronic medical record as the priority, promote hospital informatization;take advantage of the network information technology to promote the cooperation between urban hospitals and community health service institutions.Vigorously develop the remote health care services geared to the needs of rural areas and remote and border regions.Efforts should be made to establish and improve medical security information system.Speed up the construction of the multi-functional medical security information system, including fund management, expenses settlement and control, medical behavior management and supervision, management services of employers and individuals participating in insurance programs, etc.Strengthen the information system construction of urban employee’s basic medical insurance, urban residents’ basic medical insurance, New Rural Cooperative Medical Scheme and medical assistance system, and realize its connection with the information system of medical institutions, actively promote the “All-in-One Card”(a multi-purpose card), etc.to facilitate insurance(cooperative scheme)participants to receive medical services, and increase the transparency of medical services.Efforts should be made to establish and improve the three-tier(state, province and municipality)information network of drug regulation, drug testing and drug adverse reaction surveillance.And establish the information system of supply and demand of essential medicines.(xv)Establishing and improving health care legal system Efforts should be made to improve the health legislation.Quicken the promotion of the basic health care legislation, specify the rights and obligations of government, society and residents in terms of enhancing health to ensure that everyone is entitled to the basic health care services.Establish and improve health standard system, properly deal with the connection and coordination of relevant laws and regulations, and gradually establish and improve a comparatively complete health legal system in line with the basic medical and health care system.Efforts should be made to promote government administration in accordance with the law.Exercise rigorous and regulated law enforcement, earnestly improve the capacity of the governments at various levels to develop and manage health care undertakings through legal means.Make greater efforts in the popularization of the health care law, and strive to create a legal environment that is conducive to the health of the people.V.Concentrating on five key reform projects and striving to achieve remarkable results in the near future
In order to achieve results of the reform at an earlier date, efforts should be made to implement the commonweal nature of health care services, concentrate on ensuring the people’s basic needs of seeking health care services, and in light of the requirements that the people enjoy real benefits, health care workers be encouraged and regulators can easily understand the contents of the reform, strength shall be exerted on the following five key reform projects from 2009-2011.(xvi)Accelerating the construction of the basic medical security system The basic medical security system shall completely cover urban and rural residents, and within three years, the insurance(cooperative scheme)participation rate of urban employees’ basic medical insurance, urban residents’ basic medical insurance and New Rural Cooperative Medical Scheme shall all reach over 90%;and the urban and rural medical assistance system shall cover all the economically constrained households across the country.Giving priority to improving the benefit level of insurance for in-patient treatment and major diseases treated at clinics, efforts should be made to gradually enhance the fund-raising and medical security level, and by 2010, the threshold of subsidy granted by the government at various levels shall be increased to 120 Yuan per person per annum for both urban residents’ basic medical insurance and New Rural Cooperative Medical Scheme.Regarding the basic medical insurance, efforts should be made to properly conduct the credential transfer and connection and the settlement services for receiving health care services from allopatry;improve medical security management system and mechanism and effectively alleviate the burden of medical expenses on urban and rural individuals.(xvii)Preliminarily establishing a national essential medicines system Efforts should be made to establish a relatively complete system for the selection, production and supply, use and reimbursement of essential medicines through medical insurance.In 2009, the national essential medicines list shall be released, the procurement and distribution of essential medicines regulated and the prices of the essential medicines rationally determined.From 2009, the essential medicines shall be supplied to all the government-sponsored grass-roots health care institutions for medication, other health care institutions shall also use the essential medicines as required, and all the retail pharmacies shall be supplied with the essential medicines for sale.Efforts should be made to improve the medical insurance and reimbursement policies concerning the essential medicines;ensure the availability, safety and effectiveness of the essential medicines for the people, and alleviate the burden of the essential medicines expenses on the people.(xviii)Improving the grass-roots health care services system Efforts should be made to accelerate the construction of the three-tier rural health care services network and urban community health service institutions, bring into full play of the leading role of county-level hospitals, and build a relatively complete grass-roots health care services system in three years.Efforts should be made to cultivate and train grass-roots health care professionals, particularly general practitioners, and concentrate on improving the level and quality of grass-roots health care institutions;transform the operational mechanism and service modes of grass-roots health care institutions, and improve the compensation mechanism;gradually establish the system of graded diagnoses and treatment and for dual referral, so as to provide the people with convenient, fast and low-cost basic health care services.(xix)Promoting the progressive equalization of the basic public health services The state shall work out the basic public health service items, and from 2009, gradually provide urban and rural residents with the basic public health services, including disease prevention and control, maternal and child care, health education, etc.Efforts should be made to implement national major public health service programs, effectively prevent and control major diseases as well as their hazardous elements, and further improve the capacity of tackling major public health emergencies.Improve urban and rural public health service system and optimize funds provision mechanism for public health services, so that by 2009, the standard average per capita funding for the basic public health services shall be no less than 15 Yuan, and no less than 20 Yuan by 2011.Strengthen performance appraisal, and improve the service efficiency and quality, gradually narrow the gap in the basic public health services between urban and rural residents, and strive to ensure that the people shall contract as few diseases as possible.(xx)Promoting the pilot reform on public hospitals Efforts should be made to reform the management system as well as operational and regulatory mechanisms of public hospitals, and actively explore the effective forms of separating the functions of government agencies and public institutions, separating government administration and business operation.Improve the structure of hospital corporate governance.Promote the reform on the compensation mechanism of public hospitals, increase government investment, and improve the financial compensation policy for public hospitals so that the problem of “compensating the medical cost with drug sale” can be gradually resolved.Accelerate the formation of a multi-sponsored configuration for running health care institutions, and encourage non-public investors to invest in not-for-profit hospitals.Intensively reform the internal management of public hospitals, optimize service flows, regulate diagnoses and treatment behaviors, arouse the enthusiasm of health care workers, enhance service quality and efficiency, markedly shorten patients’ waiting time, and achieve the mutual recognition of the testing and inspecting results by different hospitals of the same level.Strive to facilitate the people to receive proper health care services.VI.Actively and steadily promoting the health care system reform
一个目标:建立健全覆盖城乡居民的基本医疗卫生制度, 为群众提供安全、有效、方便、价廉的医疗卫生服务。到2011年, 基本医疗保障制度全面覆盖城乡居民, 基本药物制度初步建立, 城乡基层医疗卫生服务体系进一步健全, 基本公共卫生服务得到普及, 公立医院改革试点取得突破, 明显提高基本医疗卫生服务可及性, 有效减轻居民就医费用负担, 切实缓解“看病难、看病贵”问题。到2020年, 覆盖城乡居民的基本医疗卫生制度基本建立。普遍建立比较完善的公共卫生服务体系和医疗服务体系, 比较健全的医疗保障体系, 比较规范的药品供应保障体系, 比较科学的医疗卫生机构管理体制和运行机制, 形成多元办医格局, 人人享有基本医疗卫生服务, 基本适应人民群众多层次的医疗卫生需求, 人民群众健康水平进一步提高。
四大体系:一是全面加强公共卫生服务体系建设;二是进一步完善医疗服务体系;三是加快建设医疗保障体系;四是建立健全药品供应保障体系。
八项支撑:一是建立协调统一的医药卫生管理体制;二是建立高效规范的医药卫生机构运行机制;三是建立政府主导的多元卫生投入机制;四是建立科学合理的医药价格形成机制;五是建立严格有效的医药卫生监管体制;六是建立可持续发展的医药卫生科技创新机制和人才保障机制;七是建立实用共享的医药卫生信息系统;八是建立健全医药卫生法律制度。
《医药卫生体制改革近期重点实施方案 (2009-2011年) 》的主要内容可以概括为”四项基本“一个试点”。
四项基本:一是加快推进基本医疗保障制度建设;二是初步建立国家基本药物制度;三是健全基层医疗卫生服务体系;四是促进基本公共服务逐步均等化。
医改方案指出，深化医药卫生体制改革的总体目标是：建立覆盖城乡居民的基本医疗卫生制度，为群众提供安全、有效、方便、价廉的医疗卫生服务。到2020年，覆盖城乡居民的基本医疗卫生制度基本建立。
方案公布后，有的媒体指其“实惠看得见”，但也有一些专家和媒体认为其“空洞如八股”、“‘宏观’得让人说不出意见”。
专家：催奶师不可信
“毒奶粉”事件后，催奶师作为一个专为新妈妈解决母乳喂养问题的新职业头衔在不少城市蔓延，各种各样的私人催奶师也悄然出世，声称通过按摩可以促进妈妈的奶水分泌。但专家表示，这些所谓的催奶师并不可信，通过按摩穴位并不能解决奶水不足的问题。新妈妈奶水少，通过科学的喂养与食疗就能得以缓解。
逾七成人担心“查出病”而不愿体检
中国内地知识群体普遍对健康知识缺乏基本了解，许多人认为没有不舒服就表明身体正常，担心体检会查出问题而不愿轻易进行体检。这是北京市健康保障协会最近发布的一项对5000人进行的随访调查得出的结论。
调查发现：5000人中有1/4的人认为，所在机构每年组织的基础体检已足够，认为反复检查肯定检查出毛病；有3/4认为没有不舒服就是正常，他们因害怕查出问题而不愿进行体检；只有1/5会选择专业体检机构每年进行全面的、针对自己身体特点的健康体检。
上海老人玩球练平衡
上海市在全国率先设立了老年人平衡训练项目，包括“传球和弹球”在内的这套平衡训练项目可有效减少老人日常摔倒的危险。目前正在静安区进行试点，老人们踊跃报名参加。此项目将在上海市推广。
由于身体的协调性、反应能力、注意力等方面功能逐步下降，在家中摔倒已成为老年人居家最常见的伤害。老人摔伤导致的骨折、脑血管意外、长期卧床引起肺部感染等，都是老年人致死的高风险事件。
美国每棵蔬菜都有档案
为了让民众吃得放心，美国在保障蔬菜安全上可谓用心良苦——不仅种植过程有规范的标准，生产出来的蔬菜还要有详细的档案记录。蔬菜上面贴着相应的条形码，也称为“追溯码”，上面记录着蔬菜的产地、生产日期、类别等信息，通过它还可以查询到蔬菜的具体档案。
“每一类蔬菜都有不同的生产标准，菜在什么时候播种，是否需要使用农药，药物浓度是多少……都有一套标准。我们种植蔬菜时都要严格遵守，而且每次的管理过程和检查结果都要输入电脑进行记录。”一位来自加州的菜农说。一般来说，这些记录的保留时间必须超过蔬菜的保质期，例如蔬菜的保质期为3个月，那么信息要至少保存到送货后6个月。
□声音
1. “‘老寒腿’经常泡泡腿。”
——浙江医院推拿科张杰医师介绍，“老寒腿”犯病了，可以在医生的指导下，服用具有通筋、活血、活络的中成药。还要戴护膝、护踝，保护关节，防止受凉，入睡前可用温热水洗脚，水要泡至踝关节、甚至膝关节以上，每次泡10～20分钟，以改善下肢血液循环。
2.“睡觉流口水不可小视。”
——中国医科大学附属第一医院消化内科王炳元教授提醒，如果经常出现睡觉流口水的情况，可能是一些身体疾病导致，应及时到医院检查治疗。
3.“孕10周，就该查耳聋基因。”
——解放军总医院耳鼻咽喉科主任韩东一教授指出，中国人耳聋的病因中，遗传因素约占60%。而筛查基因能从源头上阻断大部分耳聋的发生。如果孕妇和准爸爸中有耳聋家族史，如亲属中有耳聋患者，或者已经生育过聋儿的，就是耳聋高风险家庭，应对胎儿进行基因筛查。
4.“时尚大手袋，最伤女人腰。”
（征求意见稿）
根据《国务院关于印发医药卫生体制改革近期重点实施方案（2009-2011年）的通知》（国发„2009‟12号）和《中共上海市委、上海市人民政府关于贯彻<中共中央、国务院关于深化医药卫生体制改革的意见>的实施意见》，到2012年，本市着力推进十项重点工作，有效解决当前医药卫生领域的突出问题，为全面实现医药卫生体制改革的长远目标奠定坚实基础。
一、实现人人享有基本公共卫生服务
（一）实施基本公共卫生和重大公共卫生服务项目。贯彻实施国家九类21项基本公共卫生服务项目，并将具体内容增加为42项。在实施国家重大公共卫生服务项目的基础上，新增社区居民大肠癌筛查、60岁以上老人接种肺炎疫苗、新生儿疾病筛查等3项重大公共卫生服务项目。基本公共卫生服务由各级财政保障所需经费，覆盖全体居民。建立基本公共卫生服务项目和重大公共卫生服务项目管理和绩效考核制度，完善考核评价体系和方法，加强督导和检查。
（二）着力加强公共卫生服务能力建设。实施第三轮公共卫生体系建设三年行动计划。重点改善精神卫生、妇幼卫生、卫生监督等公共卫生机构的设施条件。整合市级妇幼保健资源，加快建设上海市妇幼保健中心。整合全市医学科研资源，搭建国内外合作平台，加强对重大公共卫生问题的联合攻关。加强流行病学、卫生毒理学、微生物学、环境与职业卫生、健康教育等学科建设，大力培养现场流行病学应用等公共卫生技术人才。研制和推广基本公共卫生服务适宜技术、中医药预防保健方法和技术，完善技术规范，健全管理制度和流程。探索开展气象公共卫生研究与服务。
（三）加强慢性非传染性疾病预防控制。建立以社区卫生服务中心为基础、专业公共卫生服务机构和医疗机构为支撑、全社会参与的慢性 病综合预防控制体系。实施慢性病综合防治工程，积极开展慢性病的综合干预，提高慢性病管理率和控制率。开展高危人群健康管理，探索实施高血压、糖尿病、肿瘤等主要慢性病早期筛查和病人社区综合管理。健全慢性病及相关危险因素监测和信息发布制度。
（四）加强妇幼卫生保健。推广应用孕产期适宜保健和干预技术，优化孕产期保健服务模式。完善以社区为基础的计划生育技术服务模式，提高生殖健康服务能力和水平。探索建立儿童综合发育干预、评估体系；逐步建立和规范遗传代谢病等本市常见出生缺陷筛查、诊断和管理体系，提高新生儿疾病筛查水平。开展儿童精神卫生需求评估。
（五）加强学校卫生服务。实行“医教结合”，探索“一校一医”工作模式，加强学校卫生保健人员队伍建设。将学生生长发育、心理健康纳入师范院校教育内容。开展校园内急救知识和技能全员培训。实施教室灯光改造工程，建立学生屈光发育档案。通过加强运动、合理营养等干预措施，降低学生肥胖发生率。加强学生心理健康干预和服务。加强因病缺勤缺课报告，完善学校公共卫生事件监测预警机制。
（六）全面提升公共卫生应急处置能力。以技术储备为基础，完善各类应急处臵预案和技术方案，建立实验室及现场快速检测方法，配备相应设备和试剂，加强人员培养和科学研究。以能力建设为核心，在各级医疗卫生机构开展现场侦检和采样、流行病学调查、医疗救援等方面的公共卫生应急专业技能培训。以应急处臵为重点，根据应急处臵预案，有计划地开展多种形式的演练，提高现场处臵效率。加强“120”、“119”、“110”应急系统的联动，构建立体式、跨区域、多部门协调合作的应急医疗救治系统。加强危重孕产妇会诊抢救中心、危重新生儿会诊抢救中心和专科急救中心的建设。
（七）努力提升食品药品安全保障能力。加大食品药品安全保障相关经费投入力度，建立健全基层食品药品安全监督网络和监测信息共享平台，配备食品药品相关监督设备和快速检测装备。充分运用高科技手段，逐步建立高风险食品的溯源系统，健全药品安全实时监控系统。建 立食品安全风险评估中心，发挥好食品药品安全应急指挥中心的作用。
（八）加强职业病综合防治。健全政府统一领导、部门分工协作的职业病防治工作机制。加强职业病防治机构建设，保障工作经费。强化用人单位职业病防治责任主体意识，加强职业健康监护工作。进一步发挥工伤保险和医疗救助制度的作用，搞好职业病病人的医疗救治。探索采取商业保险方式，鼓励用人单位投保，提高职工的职业健康保障水平。
（九）推进全民健康促进与健康教育。以建设健康城市为平台，结合开展健康社区、健康单位和健康生活方式行动，加强健康知识的传播，使全体市民的健康素养明显提高。围绕控油、控盐、控烟、控体重、适量运动、合理用药和控制抗生素滥用等重点，开展形式多样的健康宣传和健康促进活动，并面向全市居民家庭免费发放相关实用健康工具。在居（村）委会推广建立市民健康自我管理小组，在企事业单位探索和推广职工健康自我管理活动，全市培育1万名健康自我管理活动志愿组织者，每年组织20万名人群参加健康自我管理活动。
（十）切实保障公共卫生服务经费。专业公共卫生机构人员经费、公用经费、业务经费、发展建设经费由政府预算全额安排，服务性收入上缴财政专户或纳入预算管理。提高基本公共卫生服务经费标准，2011年起按照常住人口标准，各区县人均社区基本公共卫生服务经费标准应高于50元。切实保障重大公共卫生服务项目经费。
二、实现本市居民基本医疗保障制度全覆盖
（一）完善基本医疗保险制度。整合本市多类型的医疗保险制度，简化医保人群划分，将从事自由职业人员和个体经济组织业主及其从业人员纳入城镇职工基本医疗保险，缩小不同人群待遇差距，形成以城镇职工基本医疗保险、城镇居民基本医疗保险、新型农村合作医疗为主体的基本医疗保障制度。到2012年，基本医疗保障制度覆盖本市城乡居民，参保（合）率达到90%以上。
（二）提高基本医疗保障水平。缩小不同医保制度之间、城乡之间的医保待遇差距，搞好各类医保制度的转换衔接，逐步形成合理的医保 待遇梯度。逐步调整各类制度的医保支付比例，适度提高市民基本医疗保障水平。将城镇职工基本医疗保险统筹基金的最高支付限额从7万元提高到28万元，达到职工年平均工资的6倍，超过最高支付限额以上的医疗费用报销80%。优化城镇职工基本医疗保险参保人员综合减负办法。将城镇居民基本医疗保险统筹基金最高支付限额提高到城镇居民人均可支配收入的6倍，住院费用报销比例达到70%左右。完善新型农村合作医疗制度，2011年全面落实区县级统筹。提高新型农村合作医疗的筹资水平，逐步达到城镇居民基本医疗保险的人均筹资水平。新农合参合人员在村卫生室、社区卫生服务中心、二级和三级医疗机构门诊基本医疗费用报销比例分别达到80%、70%、60%和50%；住院基本医疗费用报销比例平均达到70%；落实新农合大病减贫补助政策，新农合最高支付限额提高到农民年人均纯收入6倍以上。相应提高新农合筹资水平，逐步与城镇居民基本医疗保险筹资水平接轨。完善新农合“以奖代补”的财政投入办法，提高财政资金使用效率。逐步提高外来从业人员医疗保障水平。
（三）完善医疗保险支付方式。完善医保定点医疗机构的总额预算支付方式，研究按照病种付费和按照人头付费的支付方式。根据本市组建的医疗联合体性质、运行方式和管理体制等情况，探索研究支持医疗联合体的医保支付方法。根据本市各级医疗机构功能定位调整，通过经济杠杆引导参保人员合理就医。探索单病种管理等支付方式改革，加强基金使用监管。
（四）探索建立老年护理保障计划。按照分步实施、循序渐进的原则，整合利用各类老年护理资源，建立多层次、多元投入的老年护理保障计划。积极研究老年护理保障筹资、支付、运行、服务、评估等政策。
（五）发展补充医疗保障制度。完善补充医疗保障制度，推动职工医疗互助保障计划、中小学生和婴幼儿住院互助基金、市民社区医疗互助帮困计划和其他各类补充医疗保险的发展。加快发展商业医疗保险，鼓励商业保险机构开发适应不同需要的健康保险产品。促进医疗机构和 商业保险机构数据和信息共享，推动商业保险机构与医疗机构的合作，探索直接结算，简化理赔手续。
（六）推进城乡医疗救助制度。搞好本市基本医疗保险、医疗救助制度和社会综合帮扶工作的衔接。增加医疗救助资金投入，调整和完善医疗救助政策，扩大医疗救助覆盖面，实施事后医疗救助向事中、事前救助转移。适时调整医疗救助的低收入标准，取消低收入家庭的医疗救助病种限制；在住院救助的基础上，逐步开展门诊救助；简化医疗救助审批程序，推进定点医疗机构实时结算医疗救助费用。针对因病致贫“支出型”贫困人群，制定政府救助和社会帮扶相结合的政策措施，切实缓解其实际困难。
三、为居民提供安全有效、公平可及、价格合理的基本药物
（一）贯彻执行国家基本药物制度。成立本市基本药物制度工作委员会，负责基本药物制度有关重大事务决策。在国家基本药物目录307种的基础上，根据本市经济发展水平和基层医疗卫生机构用药的实际情况，增加381种社区基本用药。2011年起，政府举办的基层医疗卫生机构要在国家基本药物和本市增补药物的范围内配备使用药物，并全部实行零差率销售。按照国家要求，逐步提高各级医疗机构基本药物的使用比例。
（二）建立基本药物供应保障体系。基本药物统一纳入市级药品集中招标采购体系，实行单一货源承诺、量价挂钩的集中采购方式，明显降低基本药物价格，由中标药品生产企业自主选择具有资质的药品经营企业。加强基本药物质量监管，建立核查档案。开展对基本药物生产企业处方工艺核查，严格执行GMP的有关规定。加强对基本药物配送企业监管，严格执行GSP的有关规定。对基本药物生产企业和配送企业全面实施基本药物电子监管码追溯管理。探索药品“监督检查、快速筛查、靶向抽样、目标检验”的抽验模式，发挥抽验的最大效能。完善药物储备制度，确保临床必需、不可替代、用量不确定、不常生产的基本药物生产供应。
（三）建立基本药物优先选择和合理使用制度。基本药物品种全部纳入本市各类基本医疗保险药品目录，提高报销比例。完善医疗机构用药管理、处方审核制度，加强对医务人员基本药物制度与合理用药的培训和考核。加强药品不良反应报告与监测工作，健全药品安全预警和应急处臵机制。加强基本药物制度宣传，提高市民对基本药物的认知程度，普及合理用药常识，在全社会形成有利于基本药物制度实施的良好氛围。
四、为城乡居民提供优质便捷的基本医疗服务
（一）优化医疗资源布局。制定本市医疗机构设臵规划，加强医疗资源准入管理，优化全市医疗资源布局，逐步形成“1560”就医圈，即居民步行15分钟可到达最近的医疗机构，通过公共交通工具60分钟可到达一所三级医院。优化全市范围内的三级医院布局，实施“5+3+1”工程，即在浦东新区、闵行区、嘉定区、宝山区和南汇地区各引进一所三级医院，积极支持崇明县、奉贤区、青浦区中心医院升级为三级医院，迁建金山医院。中心城区三级医院原则上不再增加床位。社区卫生服务中心原则上按照街道（乡镇）所辖范围规划设臵。
（二）合理配置医疗资源。完善由机构护理、社区护理、居家护理组成的老年护理服务体系。优化老年护理服务资源，提高老年护理服务效率，整合和利用社区卫生服务机构、部分二级医院、社会办医疗机构等现有医疗资源提供老年护理服务。探索建立老年护理分级管理模式，制定老年护理服务规范、老年护理机构出入院标准和第三方评估办法。加强康复医疗资源的配臵和人才培养，推进部分二级医院转型为康复医院。加强精神卫生工作，市级层面重点建设市精神卫生中心，区级层面完成18个区县的精神卫生中心标准化改造，加强社区精神卫生防治工作，大力发展社区精神卫生康复站。进一步完善民办医疗机构纳入医保相关政策，逐步给予符合区域卫生规划、技术质量成本优势明显的非公立医疗机构相应的医保定点待遇。
（三）健全中医服务体系。以国家中医临床研究基地为龙头，以国家中医药发展综合试验区为平台，整合市和区县两级中医医疗、教育、科研资源，促进中医药事业发展。结合市级中医临床研究基地建设，推进研究型中医医院部市共建项目。完善中医药服务网络建设，新建隶属三级中医院的中医门诊部，加强政府举办的二级中医医院建设，推进实施中医坐堂诊所项目计划。加强中医药服务能力和技术传承，建设中医临床重点学科、中医临床优势学科、推广应用中医诊疗适宜技术。建设中医药人才队伍，培育中医药高级领军人才，开设高级西医师“西学中”研修班，实施优秀中青年和“杏林新星”人才培养计划。加强国际标准化组织中医药技术委员会秘书处建设，组织研究中医医疗、护理、中药药剂质量控制相关标准。
（四）推进医疗资源整合。鼓励采取多种方式整合医疗资源，提高医疗资源利用效率。探索组建区域性医疗联合体，在本市选择2～3个区县先行开展改革试点，在探索试点取得经验的基础上再逐步向全市推广。医疗联合体实施统一运行管理、统一医保预付、统一资源配臵，创新服务模式和服务手段，推进分级医疗、社区首诊、双向转诊，为市民提供全程医疗服务和健康管理。市民选择医疗联合体签约就医，并享受就医优惠政策。
五、探索以家庭医生制度为基础的社区卫生服务新模式
（一）规范社区卫生服务。围绕社区卫生服务机构的功能定位，进一步规范和完善社区卫生服务项目和服务标准，进一步引导基本医疗服务重心下沉社区。开展示范社区卫生服务中心创建工作。深化社区卫生服务模式改革，完善全科团队服务模式。针对社区各类人群加强社区三级预防，积极开展健康管理，每年完成一定数量的适宜技术推广应用，提高服务能力。开展家庭医生制度试点工作，家庭医生负责对一定数量的人群开展疾病管理和健康管理，形成更为紧密的服务关系。试行本市居民社区家庭医生首诊、定点医疗；需转诊患者由家庭医生根据病情需要转诊至二、三级医院；探索按服务人口付费的医保支付方式。坚持服务数量与服务质量考核相结合的原则，建立社区卫生服务绩效考核指标体系，考核结果作为政府投入、医保定点资格、医务人员收入分配等的 重要依据。采取定向培养的方式，充实农村基层医师队伍，通过镇村卫生机构一体化管理，由社区卫生服务中心统一下派至村卫生室开展工作。根据服务人群数量，按照8元/人/年的标准，对乡村医生开展社区基本公共卫生服务进行考核补助。
（二）完善社区卫生服务机构收支两条线管理。加强社区卫生服务机构收支两条线管理，按照“核定任务、核定收支、绩效考核补助”的原则，强化政府责任，完善投入机制。加强对社区卫生服务机构财务监管，实行事前审批、事中监督、事后审计和绩效评估，完善预算调整机制和预决算审核制度。
（三）完善医保总额预付办法。合理确定各区县的医保预付额度，预付资金按月拨付。医保基金增量部分的预算分配适度向社区卫生服务机构倾斜。明确医保总额预付制度下的医疗机构相关财务管理操作规定。
六、推进公立医院改革试点
（一）推进公立医院管理体制改革。完善医院法人治理结构，实现所有权与经营权的适度分离，公立医院出资人代表行使公立医院所有权，推进管资产与管人、管事相结合，建立对经营者履行职责的激励和约束机制。开展部市共建，上海市政府分别与卫生部、解放军总后勤部共建卫生部在沪部管医院、第二军医大学附属医院，加强全行业属地化管理。
（二）推进公立医院运行机制改革。构建以战略规划、全面预算、绩效考核、质量管理、资产监管、审计监督为核心的专业化管理制度，促进医疗机构加强科学化精细化管理，进一步改进医疗服务。严格医院预算和收支管理，加强成本核算与控制，实施内部和外部审计制度，在大型综合医院逐步试行总会计师制度。剥离“院中院”，逐步取消公立医院特需床位。推行临床路径管理，优先使用适宜技术和基本药物。深化人事制度改革，科学合理核定人员编制，完善岗位设臵管理制度和专业技术人员聘任制度，全面实行公开招聘和竞聘上岗，探索注册医师多地点执业办法和形式。建立以岗位责任、服务质量、患者满意度等为核心的绩效考核机制。深化收入分配制度改革，实行不直接与医疗服务收入 挂钩的医院工资总额预算管理制度和以岗位工作量、服务质量为基础的内部收入分配制度，充分体现医务人员的技术劳务价值，探索建立医务人员收入的合理增长机制，调动医务人员积极性。
（三）推进公立医院补偿机制改革。在成本核算的基础上，合理确定医疗服务价格，完善政府投入机制，逐步实现公立医院补偿由服务收费、药品加成收入和财政补助三个渠道向服务收费和财政补助两个渠道转变。对符合区域卫生规划的公立医院基本建设、大型设备购臵、重点学科建设等发展建设支出，经专家论证和有关部门批准后，纳入项目库管理，所需资金由政府根据项目轻重缓急和承受能力逐年统筹安排。按服务成本保障政府指定的紧急救治、救灾、援外、支农、对口支援等公共服务经费，对承担的公共卫生服务任务给予专项补助。探索对中医院、传染病医院、精神病院、职业病医院、妇产医院、儿童医院、康复医院、老年护理机构分类管理办法，在政府投入政策上予以倾斜。在规范收支核算，合理控制成本的前提下，按照国家的有关规定，制定公立医院政策性亏损的政府补助办法。严格控制公立医院建设规模、标准和贷款行为。
（四）推进公立医院监管机制改革。建立以公益性为导向的公立医疗机构综合评价体系，评价结果作为财政投入、医保定点资格、院长绩效考核等的重要依据，健全激励和约束机制。加强医疗服务要素准入管理，严格控制医疗机构基建项目规模，严格控制大型医用设备准入。实施医疗机构“一户一档”、医务人员“一人一档”和不良执业行为积分管理制度，强化医疗服务行为监管。实施医疗保险监督管理办法，完善医保药品、诊疗项目和服务设施等管理办法，加强对定点医疗机构、定点零售药店和参保人员医疗费用支出监管。探索实行医保诚信管理、医保定点医疗机构分级管理等制度，完善定点医疗机构医保服务契约化管理。探索建立社会第三方的公立医院评价制度。推行医院信息公开制度，接受社会监督。
（五）合理控制医疗费用。不断深化医保和医疗联动改革，通过完 善医保预算管理和医保总额预付制，形成医疗机构积极主动控制医药费用不合理增长的内在动力，保障患者合理的医疗需求，提高满意度。规范医保病人自费药品和医用材料的使用。加大药品和医用耗材的集中采购力度。进一步扩大检验检查结果互认范围，减少重复检验检查。将医药费用控制作为重要指标纳入公立医疗机构院长绩效考核体系和医院等级评审体系。公立医疗机构应坚持公益性办院方向，加强医疗服务、医疗收费管理，做到合理检查、合理治疗、合理用药、合理收费，杜绝乱收费、分解收费等行为，减轻居民负担。
（六）充分调动医务人员积极性。加强宣传引导，在全社会形成尊重医学科学、尊重医务人员的社会风气，保障医患双方的合法权益。加强医德医风建设，大力弘扬救死扶伤、忠于职守、爱岗敬业、开拓进取、乐于奉献的行业风尚，促进医务人员廉洁行医。改善医务人员的工作条件，保障医务人员合理的收入待遇。合理确定医务人员工作负荷，科学配备人力资源。加强医院文化建设，畅通利益诉求渠道，加强对医务人员的人文关怀。优化医务人员执业环境，完善医疗执业保险，积极发展医疗意外伤害保险和医疗责任险，建立医患纠纷第三方调解机制，依法治理“医闹”行为。
七、加强医学学科建设和人才培养
（一）建立住院医师规范化培训制度。按照政府主导、各方参与、统一管理、规范培训的原则，积极试点探索，逐步建立与国际接轨的住院医师规范化培训制度，培养高质量的临床医师队伍。住院医师培训基地原则上设臵在本市符合条件的三级医疗机构，少数可设臵在具有显著专科优势的二级甲等医疗机构。市卫生部门根据培训基地的培训能力和全市培训需求，合理确定培训基地数量和每个培训基地招录住院医师的数量。从2010年起，每年完成2000名左右的住院医师规范化培训，全部集中在经认定的培训基地进行，其它医疗机构不再承担住院医师培训职能。各级医疗机构应当将住院医师规范化培训合格证书作为新进人员聘任临床医学类初级医师岗位和晋升临床医学类中级专业技术职务任职资格的重要依 据之一；住院医师培训对象工资待遇参照培训基地同类人员水平，并依法参加养老、医疗、失业、生育、工伤、公积金等规定的社会保障，享受国家法律法规规定以及合同约定的相关福利待遇。将全科医师培训纳入住院医师规范化培训体系，加强全科医师临床培训基地和社区培训基地建设，探索全科医师定向委托培养方式，形成一支下得去、用得好、留得住的全科医生队伍，提高基层医疗卫生服务能力。
（二）加强医学学科建设和优秀人才队伍培养。实施新一轮医学学科建设计划，加强临床医学中心和重点学科建设。建设若干所临床和基础医学研究紧密结合、转化医学机制完善、临床新技术不断涌现、疑难重症诊治技术优势明显的现代化研究型医院，争取进入国家级临床医学中心行列，提升国际学术影响力。探索建设若干个转化医学中心和市级临床研究基地。构建上海医学科学研究平台，优化完善上海市预防医学研究院、上海市中医药研究院、上海市卫生发展研究中心、上海市食品药品安全研究中心的运行机制，发挥平台作用，以解决临床实际问题、转化形成适宜技术、降低医疗费用为导向，加强联合科技攻关。推进医学领军人才、优秀学科带头人、优秀青年医学人才梯队建设计划，打造具有国际知名度的一流医学专家队伍，培育德才兼备的医学专家后备队伍。探索建立食品安全监管部门与上海高校食品安全监管人才联合培养机制，加速食品药品监管人才培养。不断完善食品安全风险评估和应急处臵专家队伍。加强院前急救人员培养，探索建立医疗救护员制度。
八、建设基于居民电子健康档案的卫生信息化工程
（一）建设统一标准的居民电子健康档案。按照国家颁布的健康档案基本架构与数据标准，结合上海实际情况，为上海常住居民建立包括个人基本信息和主要卫生服务记录两部分内容的电子健康档案，为来沪就诊的外地患者建立电子医疗服务记录。
（二）建设覆盖医疗卫生机构的健康信息网。以政务外网为主要依托，建立覆盖全市各级各类医疗卫生机构的健康信息网。构建市区两级数据共享交换平台，市级平台为全市范围跨区县、跨医疗卫生机构的健 康信息共享协同提供支撑服务，医联平台为市级医院之间以及市级医院与其他医疗机构之间的诊疗数据共享提供支撑服务，区县平台为区县内部以及与本区县以外的医疗卫生机构之间的数据共享提供支撑服务。
（三）促进医疗服务和健康信息的共享和利用。以居民电子健康档案为基础，以健康信息网为支撑，逐步形成连续、动态、个性化的健康管理模式，实现“记录一生、管理一生、服务一生”。通过医疗卫生机构之间的医疗服务和健康信息交换共享，促进各级各类医疗机构业务协同，减少不必要的重复医疗，提高检验检查、专病诊治等优质资源的利用效率。通过健康信息网，为区域医疗联合体和家庭医生制度的运作以及临床用药的使用分析和监管提供平台支撑和信息服务。
九、加快发展现代医疗服务业
（一）推进国际医学园建设。在浦东新区、虹桥商务区建设国际医学园。浦东新区上海国际医学园以先进医疗器械制造业和现代医疗服务业为核心，重点发展医疗器械及生物医药产业、医学研发、国际医院、国际康复、医护和医疗器械专业人才培养等。根据本市建设虹桥商务区总体规划，启动新虹桥国际医学中心建设，引进国际优质医疗资源，发挥本市临床医学中心的作用，建设一批高端医疗服务机构。创新建设机制，由社会资金举办营利性医疗机构，公立医院以品牌、人员、技术等要素参与，发展高端医疗服务。
（二）发展中外合资合作办医和社会办医。鼓励中外合资合作办医，引进优质国际医疗资源，建立高水平的医疗服务机构。鼓励社会资本在供给短缺领域举办医疗机构；鼓励社会资本举办以高端技术或高端服务为特色的医疗机构。
（三）发展多种形式的医疗服务业。发展与国际医疗保险接轨，符合国际医疗服务惯例的涉外医疗服务。培养涉外医师和护士队伍。鼓励社会资本参与发展涉外医疗服务市场。积极探索医疗旅游、健康管理、高端医疗、中医药保健养生、康复护理服务、整形美容等服务业态的发展。
（四）完善促进医疗服务业发展的配套政策。制定本市现代医疗服 务业发展规划。在行业准入、机构建设、运营管理及可持续发展等方面给予政策扶持，促进医疗服务业发展。完善非公立医疗机构医务人员职称评定、科研项目申请等政策，积极探索试行医师多点执业，创造有利于人才流动的宽松政策环境。发展商业医疗保险，促进商业保险公司与医疗机构之间合作，探索商业保险公司直接投资、参股医疗机构。培育并发挥好行业协会、学术团体等社会组织的作用，使其承担起行业自律、协调、服务和管理功能。
十、切实解决居民看病就医中的突出问题
（一）进一步方便居民就医。加强医院门诊力量配臵，增加专家门诊次数，加强普通门诊专家把关和指导。根据居民需求，部分社区卫生服务中心可开设双休日门诊。推行门诊预约诊疗，提供网站、电话、现场等多种预约途径，逐步提高门诊预约率。试点开展专家门诊实名制挂号。推行门诊 “一站式付费”和医保病人“先诊疗、后结算”模式，减少病人排队次数和等候时间。提供网上查询检验检查报告服务，减少患者就医往返次数。推广整合门诊，加强专科协作，方便居民就医。开展优质护理服务试点，并逐步推广到全市医疗机构。方便慢性病患者配药，对诊断明确、病情稳定、需要长期服药的慢病患者，应当开具2～4周处方用量。对部分临床必需的贵重药品，以集中定点的方式保障供应。
（二）进一步规范医疗行为。各级医疗机构不得采取任何与科室或医生经济创收直接挂钩的分配方式，禁止发生与医药促销有关的不正当医疗行为。建立医疗行为专家评审委员会，负责对是否存在过度医疗行为进行认定，认定结果记入责任医生的执业档案，并与个人职称晋升和执业资格挂钩。规范抗菌药物使用，加强对围手术期抗菌药物使用的监控，严格执行抗菌药物分级使用管理，规范多种抗菌药物联合用药。严禁各级医疗机构出现院内“假出院”等弄虚作假行为。设立违规医疗服务行为联合投诉电话，加大卫生、医保等部门联合执法力度。
（三）规范医保病人自费药品和自费医用材料的使用。医院使用自费药品和医用材料应当事先告知，征得病人或家属的书面同意。医院内 使用的所有自费药品和医用材料应当由医院提供，并进入医院的财务账目。明确规定各级医疗机构医保住院病人自费费用占总费用的比例，并实行严格考核。定期公示医疗机构自费项目的费用情况，鼓励居民举报医院违规使用自费药品和医用材料的行为。适度调整医保药品和医用材料报销范围，逐步将临床必需、疗效确切且无替代品的部分药品或医用材料纳入报销范围。
（四）改善院前急救和医院急诊服务。市、区县两级医疗急救中心要进一步挖掘潜力，增加一线值班救护车数量。合理布局急救站设臵，推进急救站标准化建设。提高随车急救医师保障待遇，探索建立医疗救护员制度，解决随车急救人员数量不足的问题。规范医院急诊接诊流程，保持“绿色通道”畅通。二甲以上医院必须确保核定的留观床位数量，加强急诊人员配备，提高收治急诊病人的能力，救护车到达后及时接车救治，确保救护车快速离院。落实就近急诊原则，一般疾病按照就近原则，送往设有急诊的距离最近的医院，各接诊医院必须落实首诊负责制。
十一、落实保障措施
（一）加强组织领导。市医药卫生体制改革领导小组负责统筹组织和协调推进改革工作。市医药卫生体制改革领导小组办公室设在市发展改革委，具体负责日常工作。各区县政府要相应成立医药卫生体制改革领导小组及其办公室，接受市医药卫生体制改革领导小组及其办公室的指导和督导，认真贯彻落实市医药卫生体制改革领导小组部署的各项工作。成立上海市卫生和健康委员会，健全政府部门之间的协调机制，形成政策合力。各有关部门要抓紧研究制定相关配套文件，细化政策措施，明确实施步骤。加强医改监测评价工作，确保改革措施落实到位，改革成果惠及全体居民。
（二）加强财力保障。各级政府要认真落实各项卫生投入政策，调整支出结构，转变投入机制，完善补偿办法，切实保障改革所需资金，提高财政资金使用效益。
（三）鼓励试点探索。对改革中的难点问题，鼓励因地制宜制定具 体实施方案，开展试点，探索新路。市医药卫生体制改革领导小组负责统筹协调、指导各项试点工作。要善于总结和积累经验，不断深入推进改革。
中共成都市委 成都市人民政府
（2009年11月9日）
根据《中共中央国务院关于深化医药卫生体制改革的意见》（中发〔2009〕6号）和《国务院关于印发医药卫生体制改革近期重点实施方案（2009-2011年）的通知》（国发〔2009〕12号）精神，结合我市实际，制定本方案。
一、指导思想、总体目标和基本思路
（一）指导思想
1、以邓小平理论和“三个代表”重要思想为指导，全面贯彻落实科学发展观，深入实施城乡统筹、“四位一体”科学发展总体战略，以实现人人享有基本医疗卫生服务为目标，坚持公共医疗卫生的公益性质，坚持政府主导和充分发挥市场机制作用相结合，推动城乡基本医疗保障、基本医疗服务和基本公共卫生服务均等化，医药卫生管理科学化，办医格局多元化，建设覆盖城乡居民的基本医疗卫生制度，不断提高全民健康水平，促进社会和谐。
（二）总体目标
2、到2011年，达到基本医疗保障制度全覆盖，基本公共卫生服务实现均等化，“全域成都”的基本医疗卫生服务体系不断完善，建立起与国家基本药物制度相适应的药品供应保障体系，公立医院改革试点和多元化办医取得突破，有效缓解城乡居民“看病难、看病贵”，实现人人享有基本医疗卫生服务。
3、到2017年，建立起均等化的基本医疗保障体系和基本医疗卫生服务体系，公共卫生服务水平进一步提高，药品供应保障体系不断完善，充满活力的医药市场体系日益完备，城乡一体的基本医疗卫生制度更加完善，基本适应人民群众多层次的医疗卫生需求，人民群众健康水平进一步提高。
（三）基本思路
4、坚持公共医疗卫生的公益性质，按照“保障均等、市场调节、民主监督”的原则，以基本医疗保障制度建设为核心，推动需方主导的医药卫生体制改革，创新医药卫生体制机制，不断扩大医药供给，优化资源配置，提高效率和质量，实现人人享有基本医疗卫生服务的目标。
5、加大公共财政对基本医疗保障、公共卫生和基层医疗卫生服务体系等医疗卫生的投入，在统筹兼顾的基础上主要投向基本医疗保障制度建设，大幅度提高保障水平。通过需方对医疗卫生机构服务的自主选择，充分发挥市场机制的作用，推进医疗卫生服务体系建设，促进公立医院改革，引导社会资源对医疗卫生的投入。改革药品和医疗服务价格管理机制，增强市场定价和市场调节功能，开展“以医养医”试点，逐步解决“以药养医”问题。通过实行向基层倾斜的差别化报销政策，引导需方分类选择医疗服务机构，促进基层医疗卫生服务体系建设，优化医疗资源配置。对可以采用购买服务方式实施的公共卫生服务等公共产品实行政府购买服务制度，提高供应质量和效率。实行公立医院管办分离，健全法人治理机制，改革人事分配制度，探索将部分公立医院改制重组为经营性医疗机构。建立健全公众对公共卫生服务和基层医疗服务的民主监督和评议制度。
二、完善城乡基本医疗保障制度
（一）逐步达到基本医疗保障均等化
6、落实国家相关政策，巩固和完善我市基本医疗保障制度，到2011年基本医疗保险参保率达到98%以上，基本实现我市户籍人员和在蓉高校大学生人人享有基本医疗保障。
7、逐步缩小基本医疗保险不同类型和档次之间的差别，实现城乡一体的均等化基本医疗保障。
（二）逐步提高基本医疗保障水平
8、到2010年，财政补贴城乡居民基本医疗保险达到180元/人·年。以后，在新增财力中逐步加大财政补贴基本医疗保险的力度，适当提高个人筹资水平。随着地方财政收入的不断增长，逐步加大财政对城镇职工医疗保险的补贴力度。
9、随着基本医疗保险基金的壮大，进一步降低基本医疗保险报销起付线和参保人员自负率，扩大报销范围，提高最高支付额度，合理控制基本医疗保险基金结余率。从2010年起，按城镇居民可支配收入6倍标准统一城乡居民基本医疗保险最高支付额，并逐步缩小城乡居民基本医疗保险与城镇职工基本医疗保险（含非城镇户籍从业人员综合社会保险）最高支付额的差距。
（三）逐步完善基本医疗保险制度
10、加大基本医疗保险对门诊医疗、大病医疗的保障力度，并纳入统筹范围。建立门诊报销制度，合理设置报销比例，改革个人医保账户管理办法。
11、改进基本医疗保险费用结算办法。在基本医疗保险报销的起付线、项目内容和报销比例等方面，健全向乡镇卫生院、村卫生站和社区卫生服务中心（站）倾斜的制度，促进“基层首诊、分级诊疗、双向转诊”制度的落实。探索按人头付费、按病种付费、总额预付等支付方式改革。
12、进一步扩大医保定点药店和定点医疗机构的范围，逐步实现患者凭定点医疗机构的处方自主选择医保定点药店购药。
13、加强基本医疗保险经办机构建设，健全保险基金监管机制，探索委托具有资质的商业保险机构经办医疗保障管理服务等有益方式，建立健全医疗保险经办机构与医疗机构、药品供应商的谈判机制，不断提高服务能力。
（四）进一步健全城乡医疗救助制度
14、充实医疗救助基金，完善医疗救助机制，资助各类城乡经济困难群体参加基本医疗保险，帮助特别困难人员解决基本医疗保障自负费用，救助患重特大疾病的特殊困难人员。
15、健全医疗救助管理机制，制定和完善医疗救助认定标准，加强医疗救助基金管理，逐步实现救助服务一站式办结，提高医疗救助工作效率。
三、建立健全药品供应保障制度
（一）建立基本药物配备和使用制度
16、政府举办的基层医疗机构必须全部配备和使用基本药物，实行基本药物按购进价格零差率销售。其他各类医疗机构也要将基本药物作为首选药物并确定使用比例，所有零售药店均应配置和销售基本药物。
17、完善基本药物的医保报销政策，将基本药物全部纳入基本医疗保障药物报销目录，报销比例明显高于非基本药物。
（二）创新药品采购和配送机制
18、二级以上医疗机构所需药品（含基本药物），在省政府指定机构公开招标的基础上可自主开展二次竞价。
19、构建覆盖“全域成都”的基层医疗卫生机构药物供应和监督“两网”体系，将农村“两网”实施范围扩大至城市社区卫生服务中心（站）。
（三）进一步加强药品质量监管
20、加强对药品生产企业的监管，严格落实药品生产质量管理规范（GMP），推行药品质量受权人制度，探索建立药品生产企业诚信制度。
21、整顿和规范药品流通秩序，严格落实药品经营质量管理规范（GSP），加强药品经营企业信用体系建设。
22、强化药品安全风险管理，加强药品不良反应、医疗器械不良事件重点监测，督促指导药品生产、经营企业和医疗机构健全风险管理制度、强化风险管理意识。
四、促进基本公共卫生服务均等化
（一）完善公共卫生服务体系
23、完善公共卫生服务体系建设规划，建立健全以专业公共卫生机构为骨干，以基层医疗卫生服务网络为基础，分工明确、信息互通、资源共享、协调互动的公共卫生服务体系。
24、健全突发公共卫生事件应急机制，完善各级政府、卫生行政部门、医疗单位应急预案和应急指挥系统，加强重大疾病以及突发公共卫生事件预测预警和处置能力。
（二）提高基本公共卫生服务水平
25、逐步提高人均基本公共卫生服务经费标准（不含全民身体健康检查项目），2010年提高到20元/人·年。
26、从2010年开始实施全民身体健康检查项目，分、有重点地对威胁群众身体健康的重大疾病开展系统筛查，努力做到“未病先防、小病先治”，使群众能及时得到有效的健康咨询、治疗和服务。
27、面向群体的公共卫生服务项目，主要采用购买服务的方式向具备条件的各类医疗卫生机构开放，对其承担公共卫生服务实行任务核定、经费核定和绩效考核。对面向个体的公共卫生服务项目（包括全民身体健康检查项目）建立“基本公共卫生服务包”，探索由服务对象自主选择服务机构的机制。
五、加强和改革医疗卫生服务体系建设
（一）完善医疗卫生服务体系
28、按照属地化管理的原则，统筹各级各类（包括各种所有制）医疗卫生机构，合理规划城乡医疗卫生机构的数量、规模、布局和功能，建立以三级综合性医院和区域综合医疗中心为骨干，以乡镇卫生院、村卫生站和社区卫生服务中心（站）为基础，布局合理、各具特色、功能定位明确的城乡医疗卫生服务体系。
（二）努力推动医疗卫生投入格局多元化
29、加大政府对医疗卫生的投入，建立政府医疗卫生投入增长机制，政府卫生投入增长幅度要高于经常性财政支出增长幅度，逐步提高政府卫生投入占经常性财政支出的比重。
30、政府对医疗卫生的投入，主要投向基本医疗保障，提高医疗卫生服务需求方的支付能力。同时，统筹兼顾对公共卫生、公立乡镇卫生院、社区卫生服务中心、公立医院和中医、传染病、精神病、职业病防治、妇幼保健等医疗卫生的投入。
31、政府对公共卫生、紧急救治等的投入，可以采用购买服务方式实施的，向全社会公开采购。
32、政府对医疗卫生的科研投入，向各类医疗、科研、教学机构和个人公开招标。
33、政府按区域卫生规划，对拟新建的医疗机构原则上不再采用直接举办的方式，可以采用建设补助、投资入股及委托经营等方式向全社会公开招标。
34、引导和鼓励社会力量投资办医。进一步开放医疗卫生市场，鼓励社会资本兴办民营医疗机构，鼓励社会资本参与公立医院改制重组。加快研究和制定各类医疗机构投资、运营的相关政策，构建平等竞争、充满活力的医疗卫生市场体系。
（三）改革政府对公立医疗卫生机构的管理
35、专业公共卫生机构和公立乡镇卫生院、社区卫生服务中心保持事业单位性质，推进经费核算和人事分配制度改革。建立健全服务对象对医疗卫生事业单位的民主监督与评议机制，并将评议结果作为对其绩效考核的重要依据。
36、推进公立医院、国有医院管办分离。医院管理部门行使出资人职责，负责医院业绩考核和国有产权监督，以出资人身份行使投融资决策权、院长选聘考核权。卫生行政部门主要承担医疗卫生发展规划、资格准入、规范标准、服务监管等行业管理和公共服务职能。
（四）探索公立医院改革
37、健全和完善公立医院法人治理机制，赋予其在重大事项决策、人事任免、设备采购等方面充分的自主权，全面推行院长负责制，建立院长公开选拔机制和目标责任制，实行院长年薪制。以人事制度和分配制度改革为突破口，建立全员聘用制和绩效工资制，加快推进离退休人员养老保障社会化。
38、推进公立医院改制重组。保留部分骨干医院的公立医院性质，其余公立医院改制重组为国有资产独资、控股、参股的经营性医疗机构（国有医院），具备条件的医院国有资产逐步退出。
39、建立由卫生行政部门、医疗保险机构、社会评估机构、群众代表和专家参与的医院质量监管和评价制度，全面推行医院信息公开制度。
（五）探索医疗服务价格管理机制改革
40、改革现行医疗服务定价机制和监管办法，增强医疗服务价格的市场定价和市场调节功能。
41、推进医药分开，取消药品加成，改革医疗服务价格，增设药事服务费、技术服务费等服务收费，探索财政补偿机制，开展“以医养医”试点，逐步解决“以药养医”问题。
（六）加强基层医疗卫生服务机构和人才队伍建设
42、按照服务范围和功能，合理确定基层医疗卫生事业单位的机构编制，加大政府对基层医疗卫生服务机构建设的投入，满足基层医疗卫生服务的需要。
43、健全基层医疗卫生人才培训制度，到2011年分别为乡镇卫生院、城市社区卫生服务机构和村卫生站培训医疗卫生人员7000人次、10000人次、5000人次，培养合格的全科医生和公共卫生人员。
44、完善执业医师从业制度，积极探索医师多点执业并获取合理回报，推动医疗卫生人才自由流动。
45、落实城市医院和疾病预防控制机构医生晋升中高级职称前到农村服务1年以上的政策，建立鼓励城市卫生专业人才到农村服务的补贴制度。
46、建立城市医院对口支援农村医疗卫生工作的制度，通过采取城市医院的专业技术骨干到基层医疗机构挂职和基层卫生人才到城市医院临床实习、培训等方式，提高基层医疗卫生人才的服务水平。
（七）建立和完善医疗卫生服务、医疗保险服务信息化网络
47、整体规划医疗卫生服务和医疗保险服务信息化建设，到2011年建立集医疗保障、电子病历、个人健康档案、公共卫生、医疗服务、卫生监督等为一体的综合性医疗卫生和医疗保险服务信息网络，完善医疗保障“一卡通”，实现信息资源共享，提高医疗卫生和医疗保险服务、管理和监督的现代化水平。
六、配套措施
（一）建立改革推进体制
48、成立成都市医药卫生体制改革工作领导小组，负责研究确定我市贯彻落实国家深化医药卫生体制改革政策的重大事项、实施方案和政策措施，组织推动并统筹协调工作中的重大问题。
49、市和区（市）县国有资产管理部门下设医院管理局，将现由卫生行政部门等管理的公立医院、国有医院和公立乡镇卫生院、社区卫生服务中心移交医院管理局，由医院管理局代表国家履行出资人职责，负责公立医院、国有医院、公立乡镇卫生院、社区卫生服务中心的管理和改革。
50、市发改委负责市医药卫生体制改革工作领导小组办公室日常工作，综合协调有关改革工作；市卫生局牵头负责基本公共卫生服务和基层医疗卫生服务体系建设；市劳动保障局牵头负责基本医疗保障制度建设；市食品药品监管局牵头负责基本药物制度建设；市医院管理局牵头负责公立医院改革的有关工作。
51、市人大常委会设立专门小组，对基本医疗保障制度改革和公立医院改革实施监督、评议、指导。
（二）建立医改效果评价机制
52、建立成都市深化医药卫生体制改革评价指标体系和动态评价机制，聘请专家小组和第三方评估机构对市和区（市）县改革实施全程跟踪，对出现的问题及时进行分析研究，对改革试验的效果进行实时评价。
（三）加强财力保障
53、市、区（市）县政府要调整支出结构，转变投入机制，改革补偿办法，切实保障改革所需资金，提高财政资金使用效益。
（四）积极稳妥推进改革试点
54、医药卫生体制改革涉及面广，情况复杂，政策性强，一些重大改革要先行试点，逐步推开。各区（市）县情况差别较大，鼓励因地制宜制定具体实施方案，开展多种形式的试点，进行探索创新。注意总结和积累经验，不断深入推进改革。
（五）加强宣传引导
“十二五”期间深化医药卫生体制改革规划暨实施方案
深化医药卫生体制改革是贯彻落实科学发展观、加快转变经济发展方式的重大实践，是建设现代国家、保障和改善民生、促进社会公平正义的重要举措，是贯穿经济社会领域的一场综合改革。“十二五”时期是深化医药卫生体制改革的攻坚阶段，也是建立基本医疗卫生制度的关键时期。为巩固扩大前一阶段改革成果，实现2020年人人享有基本医疗卫生服务的既定目标，根据《中华人民共和国国民经济和社会发展第十二个五年规划纲要》和《中共中央国务院关于深化医药卫生体制改革的意见》（中发〔2009〕6号），编制本规划。本规划主要明确2012-2015年医药卫生体制改革的阶段目标、改革重点和主要任务，是未来四年深化医药卫生体制改革的指导性文件。
一、规划背景
自2009年4月深化医药卫生体制改革启动实施以来，在党中央、国务院领导下，各地区、各有关部门认真贯彻落实中央的决策部署，按照保基本、强基层、建机制的基本原则，完善政策、健全制度、加大投入，统筹推进五项重点改革，取得了明显进展和初步成效，实现了阶段性目标。覆盖城乡全体居民的基本医疗保障制度(以下简称基本医保)框架初步形成，职工基本医疗保险（以下简称职工医保）、城镇居民基本医疗保险（以下简称城镇居民医保）和新型农村合作医疗（以下简称新农合）参保人数达到13亿人，筹资和保障水平明显提高，保障范围从大病延伸到门诊小病，城乡医疗救助力度不断加大。国家基本药物制度初步建立，政府办基层医疗卫生机构全部实施基本药物零差率销售，药品安全保障得到明显加强；以破除“以药补医”机制为核心的基层医疗卫生机构综合改革同步推进，开始形成维护公益性、调动积极性、保障可持续的新机制。覆盖城乡的基层医疗卫生服务体系基本建成，2200多所县级医院和3.3万多个城乡基层医疗卫生机构得到改造完善，中医药服务能力逐步增强，全科医生制度建设开始启动。基本公共卫生服务均等化水平不断提高，10类国家基本公共卫生服务面向城乡居民免费提供，国家重大公共卫生服务项目全面实施。公立医院改革试点积极推进，围绕政事分开、管办分开、医药分开、营利性和非营利性分开（以下简称“四个分开”）进行体制机制创新，便民惠民措施全面推开，多元办医稳步推进。各级政府对医药卫生工作的认识和执行力明显提高，实践经验和做法不断丰富，支持医药卫生体制改革的社会氛围正在形成。三年改革实践证明，医药卫生体制改革方向正确、路径清晰、措施有力，尤其是在基层取得明显成效，人民群众看病就医的公平性、可及性、便利性得到改善，看病难、看病贵问题有所缓解，医药卫生体制改革促进经济社会发展的作用越来越重要。医药卫生体制改革是一项长期艰巨复杂的系统工程。要清醒地看到，当前医药卫生体制改革中还存在一些较为突出的矛盾和问题，特别是随着改革向纵深推进，利益格局深刻调整，体制性、结构性等深层次矛盾集中暴露，改革的难度明显加大。医疗保障制度建设有待进一步加强，基本药物制度还需巩固完善，公立医院改革需要深化拓展，推进社会力量办医仍需加大力度，人才队伍总量和结构性矛盾依然突出，政府职能转变亟待加快步伐，制度法规建设的任务更加紧迫。同时，随着经济社会进入新的发展阶段，工业化、城镇化、农业现代化、经济全球化以及人口老龄化进程加快，城乡居民健康需求不断提升并呈现多层次、多元化特点，进一步加剧了卫生资源供给约束与卫生需求日益增长之间的矛盾；疾病谱变化、医药技术创新、重大传染病防控和卫生费用快速增长等，对优化资源配置、扩大服务供给、转变服务模式、合理控制费用和提升管理能力等都提出了更高要求。解决这些问题和挑战，必须持续不断地推 进改革。
“十二五”时期在深化医药卫生体制改革进程中承前启后，要在认真总结经验的基础上，进一步加强组织领导，发挥制度优势，抓住基层综合改革取得重大进展、经济持续快速发展的有利时机，不断凝聚和扩大社会共识，把改革不断推向深入，为基本建成符合我国国情的基本医疗卫生制度、实现人人享有基本医疗卫生服务奠定坚实基础。
二、总体要求和主要目标
（一）总体要求。以邓小平理论和“三个代表”重要思想为指导，深入贯彻落实科学发展观，紧紧围绕《中共中央国务院关于深化医药卫生体制改革的意见》（中发〔2009〕6号）精神，坚持把基本医疗卫生制度作为公共产品向全民提供的核心理念，坚持保基本、强基层、建机制的基本原则，坚持预防为主、以农村为重点、中西医并重的方针，以维护和增进全体人民健康为宗旨，以基本医疗卫生制度建设为核心，统筹安排、突出重点、循序推进，进一步深化医疗保障、医疗服务、公共卫生、药品供应以及监管体制等领域综合改革，着力在全民基本医保建设、基本药物制度巩固完善和公立医院改革方面取得重点突破，增强全民基本医保的基础性作用，强化医疗服务的公益性，优化卫生资源配置，重构药品生产流通秩序，提高医药卫生体制的运行效率，加快形成人民群众“病有所医”的制度保障，不断提高全体人民健康水平，使人民群众共享改革发展的成果。
（二）主要目标。基本医疗卫生制度建设加快推进，以基本医疗保障为主体的多层次医疗保障体系进一步健全，通过支付制度等改革，明显提高保障能力和管理水平；基本药物制度不断巩固完善，基层医疗卫生机构运行新机制有效运转，基本医疗和公共卫生服务能力同步增强；县级公立医院改革取得阶段性 进展，城市公立医院改革有序开展；卫生资源配置不断优化，社会力量办医取得积极进展；以全科医生为重点的人才队伍建设得到加强，基层人才不足状况得到有效改善，中医药服务能力进一步增强；药品安全水平不断提升，药品生产流通秩序逐步规范，医药价格体系逐步理顺；医药卫生信息化水平明显提高，监管制度不断完善，对医药卫生的监管得到加强。
到2015年，基本医疗卫生服务更加公平可及，服务水平和效率明显提高；卫生总费用增长得到合理控制，政府卫生投入增长幅度高于经常性财政支出增长幅度，政府卫生投入占经常性财政支出的比重逐步提高，群众负担明显减轻，个人卫生支出占卫生总费用的比例降低到30%以下，看病难、看病贵问题得到有效缓解。人均期望寿命达到74.5岁，婴儿死亡率降低到12‰以下，孕产妇死亡率降低到22/10万以下。
三、加快健全全民医保体系
充分发挥全民基本医保的基础性作用，重点由扩大范围转向提升质量。通过支付制度改革，加大医保经办机构和医疗机构控制医药费用过快增长的责任。在继续提高基本医保参保率基础上，稳步提高基本医疗保障水平，着力加强管理服务能力，切实解决重特大疾病患者医疗费用保障问题。
（一）巩固扩大基本医保覆盖面。职工医保、城镇居民医保和新农合三项基本医疗保险参保率在2010年基础上提高三个百分点。重点做好农民工、非公有制经济组织从业人员、灵活就业人员，以及关闭破产企业退休人员和困难企业职工参保工作。
（二）提高基本医疗保障水平。到2015年，城镇居民医保和新农合政府补助标准提高到每人每年360元以上，个人缴费水平相应提高，探索建立与经济发展水平相适应的筹资机制。职工医保、城镇居民医保、新农合政策范围内住 院费用支付比例均达到75%左右，明显缩小与实际住院费用支付比例之间的差距；进一步提高最高支付限额。城镇居民医保和新农合门诊统筹覆盖所有统筹地区，支付比例提高到50%以上；稳步推进职工医保门诊统筹。
（三）完善基本医保管理体制。加快建立统筹城乡的基本医保管理体制，探索整合职工医保、城镇居民医保和新农合制度管理职能和经办资源。有条件的地区探索建立城乡统筹的居民基本医疗保险制度。按照管办分开原则，完善基本医保管理和经办运行机制，明确界定职责，进一步落实医保经办机构的法人自主权，提高经办能力和效率。在确保基金安全和有效监管的前提下，鼓励以政府购买服务的方式，委托具有资质的商业保险机构经办各类医疗保障管理服务。
（四）提高基本医保管理服务水平。加快推进基本医保和医疗救助即时结算，使患者看病只需支付自负部分费用，其余费用由医保经办机构与医疗机构直接结算。建立异地就医结算机制，2015年全面实现统筹区域内和省内医疗费用异地即时结算，初步实现跨省医疗费用异地即时结算；做好基本医保和医疗救助结算衔接。完善医保关系转移接续政策，基本实现职工医保制度内跨区域转移接续，推进各项基本医疗保险制度之间衔接。加快建立具有基金管理、费用结算与控制、医疗行为管理与监督等复合功能的医保信息系统，实现与定点医疗机构信息系统的对接。积极推广医保就医“一卡通”，方便参保人员就医。加强基本医保基金收支管理。职工医保基金结余过多的地区要把结余降到合理水平，城镇居民医保和新农合基金要坚持当年收支平衡的原则，结余过多的，可结合实际重点提高高额医疗费用支付水平。增强基本医保基金共济和抗风险能力，实现市级统筹，逐步建立省级风险调剂金制度，积极推进省级统筹。完善基本医保基金管理监督和风险防范机制，防止基本医保基金透支，保障基金 安全。
（五）改革完善医保支付制度。加大医保支付方式改革力度，结合疾病临床路径实施，在全国范围内积极推行按病种付费、按人头付费、总额预付等，增强医保对医疗行为的激励约束作用。建立医保对统筹区域内医疗费用增长的制约机制，制定医保基金支出总体控制目标并分解到定点医疗机构，将医疗机构次均（病种）医疗费用增长控制和个人负担定额控制情况列入医保分级评价体系。积极推动建立医保经办机构与医疗机构、药品供应商的谈判机制和购买服务的付费机制。医保支付政策进一步向基层倾斜，鼓励使用中医药服务，引导群众小病到基层就诊，促进分级诊疗制度形成。将符合资质条件的非公立医疗机构和零售药店纳入医保定点范围，逐步将医保对医疗机构医疗服务的监管延伸到对医务人员医疗服务行为的监管。加强对定点医疗机构和零售药店的监管，加大对骗保欺诈行为的处罚力度。
（六）完善城乡医疗救助制度。加大救助资金投入，筑牢医疗保障底线。资助低保家庭成员、五保户、重度残疾人以及城乡低收入家庭参加城镇居民医保或新农合。取消医疗救助起付线，提高封顶线，对救助对象政策范围内住院自负医疗费用救助比例提高到70%以上。在试点基础上，全面推进重特大疾病救助工作，加大对重特大疾病的救助力度。无负担能力的病人发生急救医疗费用通过医疗救助基金、政府补助等渠道解决。鼓励和引导社会力量发展慈善医疗救助。鼓励工会等社会团体开展多种形式的医疗互助活动。
（七）积极发展商业健康保险。完善商业健康保险产业政策，鼓励商业保险机构发展基本医保之外的健康保险产品，积极引导商业保险机构开发长期护理保险、特殊大病保险等险种，满足多样化的健康需求。鼓励企业、个人参加商业健康保险及多种形式的补充保险，落实税收等相关优惠政策。简化理赔手续，方便群众结算。加强商业健康保险监管，促进其规范发展。
（八）探索建立重特大疾病保障机制。充分发挥基本医保、医疗救助、商业健康保险、多种形式补充医疗保险和公益慈善的协同互补作用，切实解决重特大疾病患者的因病致贫问题。在提高基本医保最高支付限额和高额医疗费用支付比例的基础上，统筹协调基本医保和商业健康保险政策，积极探索利用基本医保基金购买商业大病保险或建立补充保险等方式，有效提高重特大疾病保障水平。加强与医疗救助制度的衔接，加大对低收入大病患者的救助力度。
四、巩固完善基本药物制度和基层医疗卫生机构运行新机制
持续扩大基层医药卫生体制改革成效，巩固完善国家基本药物制度，深化基层医疗卫生机构管理体制、补偿机制、药品供应和人事分配等方面的综合改革，继续加强基层服务网络建设，加快建立全科医生制度，促进基层医疗卫生机构全面发展。
（一）深化基层医疗卫生机构综合改革。完善基层医疗卫生机构编制管理、补偿机制、人事分配等方面的综合改革措施，巩固基层改革成效。健全基层医疗卫生机构稳定长效的多渠道补偿机制，地方政府要将对基层医疗卫生机构专项补助以及经常性收支差额补助纳入财政预算并及时、足额落实到位，中央财政建立基本药物制度全面实施后对地方的经常性补助机制并纳入预算；加快落实一般诊疗费及医保支付政策，确保基层医疗卫生机构正常运转。健全绩效评价和考核机制，在平稳实施绩效工资的基础上，有条件的地区可适当提高奖励性绩效工资的比例，坚持多劳多得、优绩优酬，重点向关键岗位、业务骨干和作出突出贡献的人员倾斜，合理拉开收入差距，调动医务人员积极性。
（二）扩大基本药物制度实施范围。巩固政府办基层医疗卫生机构实施基本药物制度的成果，落实基本药物全部配备使用和医保支付政策。有序推进村 卫生室实施基本药物制度，执行基本药物制度各项政策，同步落实对乡村医生的各项补助和支持政策。对非政府办基层医疗卫生机构，各地政府可结合实际，采取购买服务的方式将其纳入基本药物制度实施范围。鼓励公立医院和其他医疗机构优先使用基本药物。
（三）完善国家基本药物目录。根据各地基本药物使用情况，优化基本药物品种、类别，适当增加慢性病和儿童用药品种，减少使用率低、重合率低的药品，保持合理的基本药物数量，更好地满足群众基本用药需求。2012年调整国家基本药物目录并适时公布。逐步规范基本药物标准剂型、规格和包装。基本药物由省级人民政府统一增补，不得将增补权限下放到市、县或基层医疗卫生机构。要合理控制增补药品数量。
（四）规范基本药物采购机制。坚持基本药物以省为单位网上集中采购，落实招采合一、量价挂钩、双信封制、集中支付、全程监控等采购政策。坚持质量优先、价格合理，进一步完善基本药物质量评价标准和评标办法，既要降低虚高的药价也要避免低价恶性竞争，确保基本药物安全有效、供应及时。建立以省为单位的基本药物集中采购和使用管理系统，明显提高基本药物使用监管能力。对独家品种和经多次集中采购价格已基本稳定且市场供应充足的基本药物试行国家统一定价。对用量小、临床必需的基本药物可通过招标采取定点生产等方式确保供应。对已达到国际水平的仿制药，在定价、招标采购方面给予支持，激励企业提高基本药物质量。提高基本药物生产技术水平和供应保障能力，完善基本药物储备制度。强化基本药物质量监管，所有基本药物生产、经营企业必须纳入电子监管。
（五）提高基层医疗卫生机构服务能力。按照填平补齐的原则，继续支持村卫生室、乡镇卫生院、社区卫生服务机构标准化建设，2015年基层医疗卫生 机构达标率达到95%以上。继续加强基层在岗人员培训，重点实施具有全科医学特点、促进基本药物使用等针对性和实用性强的培训项目。进一步规范基层医疗卫生机构用药行为。鼓励基层医疗卫生机构采取主动服务、上门服务等方式，开展巡回医疗，推动服务重心下沉，服务内容向基本医疗和基本公共卫生服务转变。建立健全分级诊疗、双向转诊制度，积极推进基层首诊负责制试点。明显提高基层医疗卫生机构门急诊量占门急诊总量的比例。
筑牢农村医疗卫生服务网底。完善乡村医生的补偿、养老政策。加强乡村医生培训和后备力量建设，逐步推进乡村医生向执业（助理）医师转变，鼓励有条件的地区通过定向培养、学历提升、岗位培训等方式加强乡村医生能力建设。积极推进乡镇卫生院和村卫生室一体化管理。
（六）推进全科医生制度建设。把建立全科医生制度作为强基层的关键举措，通过规范化培养、转岗培训、执业医师招聘和设置特岗等方式加强全科医生队伍建设，到2015年为基层医疗卫生机构培养全科医生15万名以上，使每万名城市居民拥有2名以上全科医生，每个乡镇卫生院都有全科医生。积极推进家庭签约医生服务模式，逐步建立全科医生与居民契约服务关系，为居民提供连续的健康管理服务。
（七）促进人才向基层流动。进一步完善相关政策措施，鼓励引导医务人员到基层服务。建立上级医院与基层医疗卫生机构之间的人才合作交流机制，探索县（市、区）域人才柔性流动方式，促进县乡人才联动。开展免费医学生定向培养，实施全科医生特岗计划，充实基层人才队伍。严格落实城市医院和疾病预防控制机构医生晋升中高级职称前到农村服务累计一年以上的政策。鼓励大医院退休医生到基层和农村执业。对到艰苦边远地区基层医疗卫生机构服务的医务人员，落实津补贴政策或给予必要补助。
（八）加快推进基层医疗卫生机构信息化。在试点基础上，以省为单位，建立涵盖基本药物供应使用、居民健康管理、基本医疗服务、绩效考核等功能的基层医疗卫生信息系统，提高基层医疗卫生服务水平。到2015年，基层医疗卫生信息系统基本覆盖乡镇卫生院、社区卫生服务机构和有条件的村卫生室。
五、积极推进公立医院改革
坚持公立医院公益性质，按照“四个分开”的要求，以破除“以药补医”机制为关键环节，以县级医院为重点，统筹推进管理体制、补偿机制、人事分配、药品供应、价格机制等方面的综合改革，由局部试点转向全面推进，大力开展便民惠民服务，逐步建立维护公益性、调动积极性、保障可持续的公立医院运行新机制。
（一）落实政府办医责任。坚持公立医院面向城乡居民提供基本医疗卫生服务的主导地位，进一步明确政府举办公立医院的目的和应履行的职责，扭转公立医院逐利行为。进一步落实政府对公立医院的基本建设和设备购置、重点学科发展、公共卫生服务、符合国家规定的离退休人员费用和政策性亏损补贴等投入政策。合理确定公立医院（含国有企业所办医院）数量和布局，严格控制建设标准、规模和设备配备。禁止公立医院举债建设。
（二）推进补偿机制改革。以破除“以药补医”机制为关键环节，推进医药分开，逐步取消药品加成政策，将公立医院补偿由服务收费、药品加成收入和财政补助三个渠道改为服务收费和财政补助两个渠道。医院的药品和高值医用耗材实行集中采购。政府投资购置的公立医院大型设备按扣除折旧后的成本制定检查价格，贷款或集资购买的大型设备原则上由政府回购，回购有困难的限期降低检查价格。医疗机构检验对社会开放，检查设备和技术人员应当符合法定要求或具备法定资格，实现检查结果互认。由于上述改革减少的合理收入 或形成的亏损，通过调整医疗技术服务价格、增加政府投入等途径补偿。提高诊疗费、手术费、护理费收费标准，体现医疗服务合理成本和医务人员技术劳务价值。医疗技术服务收费按规定纳入医保支付范围。增加的政府投入由中央财政给予一定补助，地方财政要按实际情况调整支出结构，切实加大投入。
（三）控制医疗费用增长。医保经办机构和卫生监管部门要加强对医疗服务行为的监管，制止开大处方、重复检查、滥用药品等行为。强化医保对医疗服务的监控作用，采取总额预付、按人头、按病种付费等复合支付方式，引导医疗机构主动控制成本，同时加强监管，规范诊疗行为、提高服务质量；逐步实现由医保经办机构与公立医院通过谈判方式确定服务范围、支付方式、支付标准和服务质量要求；严格基本医保药品目录使用率及自费药品控制率等指标考核。
加强卫生部门对医疗费用的监管控制，将次均费用和总费用增长率、住院床日以及药占比等控制管理目标纳入公立医院目标管理责任制并作为绩效考核的重要指标，及时查处为追求经济利益的不合理用药、用材和检查及重复检查等行为。加强对费用增长速度较快疾病诊疗行为的重点监控，控制公立医院提供非基本医疗服务。价格主管部门要加强医疗服务收费和药品价格监督检查。
（四）推进政事分开、管办分开。强化卫生行政部门规划、准入、监管等全行业管理职能。研究探索采取设立专门管理机构等多种形式确定政府办医机构，由其履行政府举办公立医院的职能，负责公立医院的资产管理、财务监管、绩效考核和医院主要负责人的任用。各级卫生行政部门负责人不得兼任公立医院领导职务，逐步取消公立医院行政级别。
（五）建立现代医院管理制度。探索建立理事会等多种形式的公立医院法人治理结构，明确理事会与院长职责，公立医院功能定位、发展规划、重大投 资等权力由政府办医机构或理事会行使。建立院长负责制和任期目标责任考核制度，落实公立医院用人自主权，实行按需设岗、竞聘上岗、按岗聘用、合同管理，推进公立医院医务人员养老等社会保障服务社会化。建立以公益性质和运行效率为核心的公立医院绩效考核体系，健全以服务质量、数量和患者满意度为核心的内部分配机制，提高人员经费支出占业务支出的比例，提高医务人员待遇，院长及医院管理层薪酬由政府办医机构或授权理事会确定。严禁把医务人员个人收入与医院的药品和检查收入挂钩；完善公立医院财务核算制度，加强费用核算和控制。
（六）开展医院管理服务创新。深化以病人为中心的服务理念，不断完善医疗质量管理与控制体系，持续提高医院管理水平和医疗服务质量。简化挂号、就诊、检查、收费、取药等流程，方便群众就医。大力推行临床路径，开展单病种质量控制，规范医疗行为。推广应用基本药物和适宜技术，规范抗菌药物等药品的临床使用。以医院管理和电子病历为核心，推进公立医院信息化建设。全面推行便民惠民措施，大力推广优质护理，优化服务模式和服务流程，开展“先诊疗、后结算”和志愿者服务。积极推进区域统一预约挂号平台建设，普遍实行预约诊疗，改善就医环境，明显缩短病人等候时间。发展面向农村基层及边远地区的远程诊疗系统。
（七）全面推进县级公立医院改革。县级公立医院是农村三级医疗卫生服务网络的龙头。“十二五”期间要把县级公立医院改革放在突出位置，以破除“以药补医”机制为关键环节，统筹推进管理体制、补偿机制、人事分配、采购机制、价格机制等方面的综合改革；加强以人才、技术、重点专科为核心的能力建设，巩固深化城市医院对口支援县级医院的长期合作帮扶机制，经批准可在县级医院设立特设岗位引进急需高层次人才，力争使县域内就诊率提高到90% 左右，基本实现大病不出县。2015年要实现县级公立医院阶段性改革目标。
1 公立医院改革和构建医疗服务体系的基础
《医改何去何从——政策研究者郝模教授纵论医改突破口(三)》(刊登于本刊2011年第1期第1页)一文分析出,如果百姓担忧的看病贵等问题不解决,没有人会承认医改成功。就现实而言,公立医院是医疗服务体系的骨干力量,看病贵等问题也主要聚焦于此。公立医院改革如果不首先解决看病贵等问题,从而求得突破,没有人会满意构建“完善”后的医疗服务体系,百姓得实惠的目标就无法实现。
近期来看,由于公立医院改革仅是试点,所以从全国范围来看,期望公立医院改革全面解决“看病贵”问题是不现实的,最多在部分试点地区可能取得突破性进展。“冰冻三尺非一日之寒”,看病贵等问题之所以会成为各方关注的焦点,与公立医院长期形成的扭曲的补偿机制密切相关。根据表1,如果采用“总额预算+按服务单元付费”组合支付方式,能彻底扭转医疗机构“多开点药、多做检查”行为倾向而完善补偿机制,消除百姓看病贵的感觉,最大程度避免“拉大网检查”等诱导服务现象的发生,同时解决药品滥用、医疗机构只管赚钱等问题[1]……总之,公立医院改革试点的基本目标已经达成。
就医改中的一些关键措施而言(表1),在限定业务收入总额和按单元收费情况下,成本核算将是医院收益最大化的最有效管理手段,“医药分开”的实质实现,体制改革有了基础、临床路径有望走向适宜……另外,在前述改革效果基础上,如配以包括人事和工资制度改革在内的各种考核、激励和奖惩办法,有望解决困扰多年的医德医风(红包、回扣)、服务态度和质量问题。
可见,根据组合支付方式的预期效果来看,医疗领域存在的看病贵等一系列问题得到解决后,众多改革措施获得了落实的必要条件,医疗服务体系构建就有了基础,公立医院改革试点成功也获得了前提。
2 建立规范的药品供应保障体系的基础
从医改方案来看,药品供应保障体系涉及到的主要政策措施为“基本药物制度建设”、“推动医药企业提高自主创新能力和医药产业结构优化升级”、“加强药品研究、生产、流通、使用、价格和广告监管”。
目前药品市场产、销、购、用各个环节混乱的现象依旧,给监管带来极大困难。特别是,如期望单纯从药品领域着手解决问题,往往事倍功半,甚至无功而返,政府多次降低药价而百姓负担不降反升[2]、医保目录扭曲[7]等现象的出现就是明证。而如果实行“总额预算+按服务单元付费”组合支付方式后,在药品市场的主导方——医疗机构向需方“少开点药、卖便宜药”的导向下,将形成低价药易销的局面,由此将消除药品市场一系列的混乱现象(表1),产地等五方面的适宜性都将提高,“低水平重复建设”企业的生存空间受到挤压,具规模效益、努力研发创新的企业将获得更大发展空间,产业整合升级将成为现实,监管部门的一些监管目标自动达成,监管部门这时候理应回归其本职工作。此外,基本药物目录将由于医疗机构“少开药、开低价药”的引导而趋向合理,由此基本药物制度建立将具备坚实基础,进而有望完善药品供应保障体系。
总之,在一个混乱的药品市场中,是无法达成建立规范的药品供应保障体系的目标的。支付方式改革后,预期可消除产、销、购、用四方问题,形成有序的药品市场,这为建立健全药品供应保障体系提供了基础,也为建立国家基本药物制度提供了前提。这时候,以基本药物制度为基础的药品供应保障体系可望发挥缓解“看病贵”的作用。
3 完善医疗保障体系的基础
国际公认医疗保障制度的目的是为建立风险共担机制而化解高额费用风险,同时为医疗机构发展提供稳定的经费保障。然而,医保机构或者说医保基金稳定运作的关键是确保收支平衡。也就是说,只有消除医保机构的这种担忧,它才可能把实现上述两个目的作为工作目标。否则的话,医保机构根本无暇顾及医保制度能否有效达成制度本身的目标,有关改革措施就缺乏推进基础。根据《为医保收支平衡提供稳定的环境》(刊登于本刊2011年第1期第35页)一文论证结果,医保机构的确面临着收支失衡的风险。而要解决该难题,从现实和长远来看,唯有控制医疗费用合理增长。
从表1可见,在“总额预算+按服务单元付费”组合支付方式实行后,医疗费用总额预算将确保医疗费用合理增长,按服务单元付费使得医疗机构的诊疗行为从“多开药、开贵药”转变为“少开药、开便宜药”,由此有望杜绝基金超支。也就是说,几乎可彻底解决医保机构最担忧的问题。这时候,医保机构理应为百姓和医疗机构提供最好的保障,至少“收支平衡”再也不能成为医保机构不作为的“借口”。这种情况下,医改方案中涉及到的各项医保具体措施,如提高覆盖面和保障水平等将变得容易落实,城乡一体化的基本医疗管理制度也有望实现。
总之,通过支付方式改革,有效化解了医保机构收支失衡的风险,建立和完善医疗保障体系就有了基础。
4 健全基层医疗卫生和公共卫生服务体系的基础
基层卫生机构与二、三级医疗机构一样,同样面临着补偿的压力和动力,“多开点药、多做检查”也是基本行为导向;和公立医院相比,其差别在于,因为缺少高新检查配置,补偿更多地依靠药品收入,“以药养医、重医轻防”是基层机构无奈的选择。之所以基层就医看似较便宜,主要是因为基层机构的服务项目较少、能力偏弱。所以,在同样的政策环境下,期望通过引导一般诊疗下沉到基层而解决“看病贵”是不现实的。如果对基层卫生机构政策倾斜,大幅度增加投入,有可能大幅增加检查等服务项目,从而助长了“看病贵”。
实行组合支付方式以后,即使基层卫生机构服务项目明显增加,这时候医生和机构的基本行为倾向还是“少开点药、少做检查”,因为,合理诊疗有望带来更多的净收益。这时加强基层硬件和服务能力建设,除了可有效缓解“看病贵、看病难”,还有可能把工作重点放在提供基本公共卫生服务上来。健康教育、预防、保健、康复和计划生育技术服务工作将会落实到位,至少较之以往会做的更好。根据表1可见,众多改革措施也将因支付方式改革而自动落实或者具备落实的前提。
对于公共卫生机构或者基层卫生机构的基本公共卫生服务提供来说,公共职能缺位是首要问题,其根源同样在于补偿机制问题[5]。可惜的是,这方面适宜投入的长效机制能否建立还有待观察。从公共卫生服务均等化的工作来说,人均15元基本公共卫生服务经费是否足够值得怀疑,要真正落实到位,同样离不开适宜和稳定增长的投入机制支撑。
总之,通过改革支付方式,扭曲的补偿机制理顺后,基层卫生服务体系的各项建设措施都比较容易落实,至少预防等非医疗工作会做得更好,健全基层医疗卫生服务体系就有了基础。对于公共卫生机构与基层卫生机构的基本公共卫生服务来说,其职能落实的关键是建立适宜和稳定增长的投入机制。
参考文献
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[2]郝模.医药分业的利益驱动分析[J].中华医院管理杂志,2004, 24(1):42-45.
[3]陈晓玲.“看病难、看病贵”问题分析[J].经营管理者,2010 (2):76.
[4]郝模,王志锋,包江波,等.促使药品市场有序发展政策研究概论[J].中国卫生资源,1998,1(1):15-19.
[5]于竞进,于明珠,郝模,等.《重塑中国疾病预防控制体系政策研究》研究结果简介[J].卫生研究,2005,34(1):5-7.
1月21日，国务院常务会议审议并原则通过《关于深化医药卫生体制改革的意见》和《2009～2011年深化医药卫生体制改革实施方案》。会议决定，重点抓好基本医疗保障制度、国家基本药物制度、基层医疗卫生服务体系、公立医院改革和基本公共卫生服务逐步均等化等五项改革，预计3年内各级政府将为此投入8500亿元资金。
这一刻，距离新一轮医改筹谋的2006年，已过去近3年；距离中国医疗卫生体制改革启动的1997年，已过去约12年。
股市迅速作出反应。1月22日，医药股高开，万东医疗、通策医疗、新华医疗和四环生物4支股票涨停。
国家发改委社会发展司健康保障处处长任伟告诉记者，医改方案的宣传报道工作将在春节后有计划地展开，目前尚无更多信息发布。
据一位知情者透露，医改的话题在近几年始终保持较高关注度，政策的风吹草动都会被媒体细致呈现，“新医改方案的内容其实并不‘新鲜，但8500亿的高额投入却是首次披露，这笔钱将怎么花值得关注。”
深度参与清华版医改方案设计的清华大学公共管理学院副教授沈群红评论道：“医改的核心问题并不仅仅是加大投入，而是合理科学地激励、依靠与引导医务人员提供可靠、安心的医疗服务。”
加大投入此其时也
广东省卫生厅副厅长廖新波2009年1月16日在博客上发表《公立医院改革如同鸡肋?》，文章认为，“政府财力投入是实行有效医改最重要的保证”。
廖新波以官员身份公开讨论卫生领域的大事小情，在卫生圈里已有一定知名度。他强调政府财力的观点，具有一定的代表性。
2003年非典型性肺炎爆发，暴露出中国公共卫生投入严重不足，要求政府加大公共卫生投入的呼声不绝于耳。
政府加大投入应投向哪里7“补供方”一派的观点认为，政府应通过预算拨款的方式，支付公立医疗机构运转的全部或部分成本；“补需方”一派的观点认为，政府应出钱购买医疗服务，完善医疗保障体系。
这两派观点的争论，直到2008年10月《关于深化医药卫生体制改革的意见(征求意见稿)》出台都不曾停止。
辩论激烈，源于以下基本事实——长期以来，政府部门对公共卫生的投入严重不足，目前对医疗卫生事业的投入不到6％，而国际上许多不发达国家的投入也多超过7％，发达国家更是达到15％～20％。
卫生部2008年5月公布的《2008年中国卫生统计提要》显示，在2006年的卫生总费用中，政府卫生支出占18.1％，社会卫生支出为32.6％，个人卫生支出是49.3％。
不少学者认为，政府投入趋于萎缩，个人承担的卫生支出陡然上升，是“看病贵”的重要原因。
2006年10月，中共中央政治局举行第三十五次集体学习。中共中央总书记胡锦涛强调，要坚持公共医疗卫生的公益性质，深化医疗卫生体制改革，强化政府责任，严格监督管理，建设覆盖城乡居民的基本卫生保健制度，为群众提供安全、有效、方便、价廉的公共卫生和基本医疗服务。
2007年中共十七大报告将卫生事业列入以改善民生为重点的六大社会建设任务之一。
2008年11月，国务院又把加快医疗卫生事业发展、加强基层医疗卫生服务体系建设纳入进一步扩大内需的十项措施之一，以应对全球金融危机。
有评论认为，政府此次安排4万亿元资金力求拉动国内需求，很重要的就是要解除城乡消费者当前和长远的忧虑，从而释放其消费活力。而从社会关注度最高的三大民生领域——住房、教育和医疗来看，前面“两座大!广通过住房保障体系建设、城乡免费义务教育等政策，已在开展“移山”的工作，只有医疗卫生还未见大的举措。
8500亿怎么花
“这次承诺投入8500亿元资金，也是对公众要求减轻医疗负担的一种回应。但中国的问题向来复杂且叠加，有投入不足的问题，同时也存在投入不当的现象。因此，这笔钱究竟怎么投尚需讨论。”一位医改专家认为，投入领域之一当是“看病贵”的源头之一——医学的基础研究、技术和药物研发等领域。
卫生部统计信息中心主任饶克勤等人的研究表明，2005年中国各种疾病的直接和间接经济负担占GDP的12.9％，如果按照现在的发展趋势，到2020年将占到GDP的20％以上。
2008年10月，卫生部、世界卫生组织等联合举办的“健康与发展高层论坛”传出消息：中国因常见慢性病住院一次一般要花掉城镇居民人均年收入一半以上，费用是农村居民人均年收入的1.5倍。
“疾病造成的负担连美国都难以承受，何况中国这样一个发展中国家。”一位深度参与医改方案的人士对记者说，“这一方面要求中国走出重治疗轻预防的误区，大力推广健康教育。另一方面，则需要医疗界不断提高科研能力，寻找适宜、价廉的技术和药物，不能一味依赖国外的高新技术、新药成果。”
这位人士称，资金投入的第二个领域应当是公共卫生。“这已经在社会各界形成共识。”
新医改方案准备重点抓好的5项改革之一，就是促进基本公共卫生服务逐步均等化，具体内容包括制定并实施国家基本公共卫生服务项目，从2009年开始逐步在全国建立统一的居民健康档案，增加公共卫生服务项目、提高经费标准等。
“医疗救助应是政府投入的第三个领域。”这位人士说。此前，清华版医改方案已经建议政府考虑设立中央紧急医疗救助基金等方式，满足一部分经济困难群众的医疗需求。
如何取得预期的成效
问题的关键仍是——补供方还是补需方?
“补供方、补需方的辩论本身没有错，但声音都集中在这个话题上，容易造成公众的误解，以为医改只要加大政府投入就能成功。”沈群红对记者说，“事实上，医改的核心问题并不是简单地增加投入，而是以医疗安全和医疗质量为中心，建立以患者为中心的医疗服务模式，其间需要恢复医患之间的信任、和谐，让公众能够安心、放心地接受医疗服务。甚至更深入地说，医改的成功在一定意义上还取决于公众的期望值是否合理。”
沈群红说，世界上堪称比较成功的医疗改革都需要认真处理人力资源的问题，而我国现有的医疗服务补偿和激励机制均不到位，难以有效调动医务工作者和医疗机构的积极性。新医改方案对公立医院内部管理制度改革的高度重视，应该有助于改进现状。一些医疗机构在内部人事制度改革上的积极努力，已取得了医疗费用降低、医疗安全提高、医疗服务规模扩大的初步成效，这也在一定程度上显现了公立医院内部制度优化的重要意义。
她认为，医疗服务是一种基于长期积累形成的对疾病进行诊断和治疗的行为，具有整合活动的属性，是医疗安全的关键，也是医务工作者价值的所在。医疗服务机构的整合功能则表现为帮助患者降低分散获得医疗资源的成本。
但在现实中，医疗机构和医务工作者的这种贡献往往遭到忽略，扭曲的补偿和激励机制甚至迫使医院、医生为自身利益过度医疗，致使医生、患者、医院三者之间彼此都存有怨言。
2006年中华医院管理学会对全国270家医院进行的调查显示：有超过73％的医院出现过病人及其家属殴打、威胁、辱骂医务人员的情况；有近60％的医院发生过因病人对治疗结果不满意，聚众围攻医院和医生的情况；有近77％的医院发生过患者及其家属在诊疗结束后拒绝出院且不缴纳住院费用的情况；有近62％的医院发生过病人去世后，病人家属在医院内摆放花圈、烧纸、设置灵堂等事件。
近几年来，砍杀医生、拒绝在手术知情同意书上签字导致亲属死亡等极端案例亦不时传出。
身处这种医患环境的医生，同时面临高强度的工作压力。据记者了解，许多医生在门诊日时，不敢喝水，没空吃饭，在办公桌前往往一坐就是半天、一天。
沈群红说，不少医生、学者都在呼吁转变公立医疗卫生机构的运行机制，提高医生待遇，但是，医疗服务的定价与补偿问题在医疗卫生体制改革中极为敏感，也相当复杂。倘若这个问题处理不当，医疗服务体系的治理模式不能完善，那么，比8500亿元更大的投入也可能难以见到预期的成效。
链接
新医改大事记
2003年：非典型性肺炎暴露出中国公共卫生体系的薄弱环节，学术界开始反思1997年的医疗卫生体制改革。
2005年：国务院发展研究中心报告称中国医疗卫生体制改革“从总体上讲是不成功的”，引起强烈反响。
2006年：6月，国务院筹划启动新一轮医改；9月，16个部委组成的医改协调小组成立；10月，胡锦涛总书记在中共中央政治局第三十五次集体学习时强调建设覆盖城乡居民的基本卫生保健制度，强化政府责任。
2007年：医改协调小组委托包括北京大学、世界卫生组织等在内的多家海内外机构提交、讨论医改方案。
2008年：温家宝总理在4月与9月两次主持召开深化医药卫生体制改革工作座谈会，向社会征求意见；10月，《关于深化医药卫生体制改革的意见(征求意见稿)》面向全社会征求意见，共收到反馈意见3.5万余条。
2009年：1月21日，国务院常务会议通过《关于深化医药卫生体制改革的意见》和《2009～2011年深化医药卫生体制改革实施方案》，新一轮医改方案正式出台。
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