中低收入国家不同医疗保障制度设计对抵御疾病经济风险的作用研究

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

Study on the Role of Financial Risk Pooling of Different Health Security Mechanisms in Low and Middle Income Counties

Objectives Through a systematic review, to summarize and describe various health security mechanisms of protecting financial risk from illness in low and middle income countries (LMICs), and to analyze causes that lead to different effects in financial risk protecting. Methods Search words were chosen by both health policy experts and search coordinators after discussion and pilot. Twenty-four electronic databases, websites of 11 health institutions, and the search engine Google were searched. Any original study to evaluate the role of financial protection of health security mechanism in LMICs was included. Pre-designed data extraction form was used for collecting strategies and study method of included studies, and extracted information was analyzed and described. Results Fifty-two studies were included, and 56 specific health security mechanisms were categorized into 6: community-based health insurance, social health insurance, health sector reform, subsidy, user fee, and new rural cooperative medical scheme (NRCMS) in China. Forty-two mechanisms had positive effect in financial protection, 6 were negative, 5 had no effect and the effect of the other 2 was unclear. Conclusion Mechanisms that produced positive effect can be summarized as: setting up of co-payment rate, design of benefit packages, providing free care for vulnerable population, delivering primary health care directly in remote area, and Chinese NRCMS. Mechanisms to protect the poor from financial risk of illness include: government provides health insurance, providing free care and setting up different co-payment rate according to income. The failure of health security mechanisms can be ascribed the deviation from its original goal of health security mechanism design, due to various inner or external causes.