A Study On The Value Orientation And Realization Mechanism Of The Reform Of China's Healthcare System

The deepening reform of China's medical and health system is implemented at a time when there is little theoretical consensus and much dispute. As the health system reform deepens, a number of topics emerge which require careful studies, and "the value orientation and it's realization mechanism of the health system reform" is central to the issue. Based on the analysis of ethical dilemmas in the health system reform, this project conducts its research, which is financed by "the Ministry of Education's Humanities and Social Sciences Fund" and "the Shandong Provincial Social Science Fund", from the unique perspective of humanistic medicine.The existing studies on value orientation and realization mechanism are mostly confined in the social medicine and have made few in depth and systematic discussions from the angle of humanistic medicine. This paper looks at the value orientation and realization mechanism in deepening China's medical and health reform from the perspective of humanistic medicine, especially that of the bioethics.The study uses literature analysis, conference seminars, field surveys and case studies in association with the theories and approaches of humanistic medicine in an attempt to clarify the general understandings on the theoretical level, and tries to make a contribution to the deepening reform of China's health system. On the one hand, forward-looking discussions are made in respect to the value orientation and realization mechanism of the reform, followed by policy recommendations that are beneficial to the ongoing pilot reform with public hospitals. On the other hand, with the deepening reform of the health system, the current reform measures are reviewed in retrospect to facilitate timely and continuous adjustment and improvement of the medical polices.This project has theoretical and practical values. It opens a new area of research for the humanistic medicine and the social medicine in China, provokes thorough reflections on the reform of China's health system that are going on for many years and works to smooth benefit-based relationships and the implementation of deeper reforms of the health system. The project clarifies the objectives and the essential values of the health system by analyzing the three goals of the health sector, i.e. "health promotion", "reactive enhancement" and "fair financing for health services", and proposes three value targets, i.e. "quality", "fairness" and "efficiency". Through the comparison of the values offered by different healthcare systems around the world, the project maintains that, from the financing perspective, the degree of fairness is, in the descending order, "National Healthcare System→Social Medical Insurance→Saving-based Medical Insurance→Community Medical Insurance→Commercial Medical Insurance→Self-paying Medical Service", which means the national healthcare system the best and the self-paying medical service is the worse in the fairness of fundraising. From the efficiency and quality, the degree of "comprehensiveness and depth" of market competition serves as a decisive factor. In this sense, the "national healthcare system" has the lowest efficiency and quality while the "commercial medical insurance" and the "self-paying medical service" have the highest. In the context of the times, the project looks at the value of the health system under a planned economy rationally and objectively and holds that the overall value orientation of the policies and reform of the health system that has been progressing to this day since 1980s is on the right track and always centers on quality, efficiency and fairness, despite some deviations that have occurred in the implementation of the values and certain specific policies.Fairness is one of the value orientations in the health system reform. The project starts off by explaining the concept of fairness from the angle of humanity in four aspects, "the Concept of Fairness", "the Ethical Principles of Fairness and the Fundamental Issues of Fairness", "the Ethical Value of Human Rights" and "the Relationship between Fairness and Equality". It then reveals the connotation and the structure of fairness in medical services and health care and puts forward that "the human rights to health" is the ethical foundation for fairness in medical services and health care. From the two aspects, "Fairness in China's Health Sector" and "Importance of Fair Value in the Scientific Development of Medical Services and Health Care", analysis is made concerning the urgency and inevitability of fair value in deepening the health system reform in China. Based on this, it is proposed that the establishment and improvement of the basic medical and health system is the strategy while the health care for all is the tactic towards the realization of fair value in the medical sector. The study takes "the health system reform in the Shenmu County, Shanxi" as a case and discusses the fairness. In the Shenmu health system reform, the "basic medical insurance system for employees" and the "cooperative medical scheme for urban and rural residents" are connected with the national basic medical security system. The cost beyond the free medical fund is covered by the County's government budget. The comprehensive "free medical service for all" has provided fair medical and health services in terms "financing", "provision", "utilization" and "output". In short, the scheme has addressed the fairness issue in medical and health services. As the study in pursuit of fair value, the Shenmu health system reform has neglected efficiency in its design, and the problem is yet to be solved by making systematic improvements.Efficiency is another important value orientation in the health system reform. In the project, the humanistic connotation of efficiency is revealed and the ethical value of efficiency is analyzed. Based on the review of the practices of efficiency and fair value, the relationship between fairness and efficiency is discussed and the questions as to "how to treat fairness and efficiency" and "how to treat equality and efficiency" are raised. The nature of medical and health efficiency is revealed, some types of medical and health efficiency are presented and the prejudices against the value of medical and health efficiency in the health system reform in theory and in practice are pointed out:1) the macro and micro efficiencies of medical and health services can be hardly unified; 2) in the medical and health sector, financial benefit and social benefit are incompatible, and; 3) the pursuit of financial benefit is the root cause for many problems in the medical and health sector. In the project, the efficiency of China's health system is evaluated from three aspects, "Lack of System Efficiency", "Underperformed Allocation Efficiency" and "Low Technological Efficiency". On this basis, strategies to improve the efficiency of the health care system are proposed:enhance system efficiency, allocation efficiency and technological efficiency through systematic construction, orderly competition and stronger government functions respectively. The project takes "public welfare" as a case and studies the systematic and ethical problems in the improvement of efficiency. It points out that the value orientation of "public welfare" in the new health system reform is yet to be clarified on the theoretical level, and maintains that the health system reform policies where "achieving public welfare of the medical and health cause is the government responsibility" are scientific and correct. However, "making public hospitals draw back public welfare" is not a good policy. Based on the ethical discrimination of "public welfare", the project explains the "ethical behavior of public welfare" from the theoretical perspective, finds an ethical position for the "public welfare of medical and health services", and maintains that public hospitals can hardly return to public welfare under the current system where the "financing of medical cost" and the "provision of medical services" are separate. However, the cause of medical treatment and healthcare obviously retains characteristics of public welfare, as it concerns the life and well being of every individual. In that way, how can we understand, and indeed, achieve the public welfare of the medical and health cause? The project insists that governments at all levels are responsible for the public welfare of medical and health services, and hospitals are only a means towards that end.Market mechanism is one of the most important mechanisms for the value orientations of the health system reform. The project analyzes the ethical nature of the market mechanism from three aspects, "Clarification of the Concept of Market Economy", "Ethical Analysis of the Broker Hypothesis and Market Mechanism" and "Ethical Value of Market Mechanism", and maintains that the market mechanism is the freest, fairest and the most efficient. Based on the object analysis of the medical and health market, it also believes that the market mechanism is the general direction of health system reforms around the world and is determined by the particular medical and health system that China has opted for. In the end, the project analyzes how the market mechanism achieves the value orientation of fairness and efficiency in the policies and practice of the health system reform. The project takes the "health system reform in Suqian, Jiangsu Province" as a case to discuss how market mechanism is introduced into the health system reform and realizes the value orientation. The Suqian health system reform started off in controversies around its mercerization. As the reform deepens, the City of Suqian gets to taste the flavor of success. The project analyzes the motivation of mercerization of the Suqian health system reform that embraces the market, and maintains that its market mechanism is designed by "nurturing the subject of market" and the "quartering principle". Introducing the market mechanism into the Suqian health system reform, on the one hand, has promoted the medical and health efficiency, reduced the cost of medical services, increased the income of service providers and encouraged a large quantity of social resources into the medical and health sector; and on the other hand, improved fairness as the government budget now subsidizes the buyer instead of the supplier, which facilitates the fair financing of the medical and health services. The Suqian health system reform ensures the development of public security and healthcare and works towards the equalization of public health. The entry of social capitals leads to the increase of medical resources in large qualities, which is beneficial to the fairness of medical services.The government-led market mechanism is another important mechanism to realize value orientation in the health system reform. The study maintains that the necessity of the government's leading role in deepening China's health system reform is determined by "the market failure in the medical and health sector", "the protection of social welfare" and "the experience and lessons from China's early health system reform". The study points out that the strategies and tactics in deepening the health system reform should be led by the government. The establishment of a basic health system led by the government is a strategic choice, while the medical insurance for all and improved social security guided by the government is the key tactic, in deepening the health system reform. Particularly from the angle of Confucian bioethics, the study analyzes the family ethical value and "love with distinctions", and proposes to establish "Family Medical Accounts". In particular, the government's leading roles should at least include a good insurer, a good payer, a good regulator, a good market promoter, a good resource allocator and a good public health provider. Finally, the study also identifies several mistakes in the government leading roles and insists that government leadership does not mean the leading position of public medical institutions or government arranging everything, nor does it mean a planned economic system or highly centralized administration, and that government investment does not conflict with the market.