ABSTRACT A Study of Key Decision-making Factors of Coping Global Budget System and Reformed Hospital Accreditation of a Regional Military Hospital Since the implementation of Global budget system in 2002, the constant controversy is continuous. In addition, the fulfillment of Reformed hospital accreditation is related to the amount of insurance payment. Under this double pressure, the medical institutions generally face the dilemma of operating difficulties. Besides these pressures, the Military hospital also has problems of budget and staff reducing. How to draft and execute the business strategy to achieve sustained development is a serious and important issue. In this study, a regional military hospital was chose as a research case. We point at analysis of medical industry environment , literatures review and ways of monitoring of Global budget system and Reformed hospital accreditation of research hospital. According to the characteristics of Global budget system and Reformed hospital accreditation, we adopted the Saaty¡¦s Analytic Hierarchy Process (AHP) to establish individual multi-estimate criteria models of the key decision-making factors of Global budget system and Reformed hospital accreditation of the hospital. And then by AHP qualitative and quantitative questionnaires, undertook research and analysis of various key decision-making factors. Finally, the Analytic Hierarchy Process was applied to calculate the weighting and to sequence the priority of these factors. To find out which hospital management operation system should be strengthen. The results of study showed that in light of coping Global budget system, the ¡§strategic management¡¨ is the most important key decision-making factors, which ¡§Cost control and financial management¡¨ and ¡§ Just distribution of reward¡¨ are the top priority. In addition, ¡§ Raise the medical quality of service¡¨ and ¡§quality of medical manpower¡¨ to fight for extra Global budget and own expense items are the important strategy of broadening resources. In the light of coping the Reformed hospital accreditation, the ¡§Decision making capacity¡¨ is the most important factors, particularly the ¡§leader¡¦s leadership of the decision-making¡¨. ¡§Reformed hospital accreditation progress-control table¡¨ and the ¡§Information system of management of Reformed hospital accreditation¡¨ can standardize the preparatory work as well as the control over the progress of preparations. ¡Ô

Since the global budget system carried out by National Health Insurance Bureau in 2003, hospital autonomy management practiced in 2003 as well as reviews carried by specialized doctors system established, local hospitals have faced critical impacts. The fluctuating point reimbursement was applied, it not only restrains the reimbursement received by the hospitals, but also causes management difficulties for local hospital as the fluctuating points shrink year by year. The number of western medical hospitals is decreasing. The number in 2000 was 575, but now only 500 local hospitals operate in Taiwan. For survival, local hospitals have to establish sound financial system in order to deal with changing national health insurance policies. On the other hand, they are encouraged to use strategy management theories to promote the competitiveness for local hospitals to well control their expenditures and create their income. The study has analyzed the statistical data from Statistical Office, Department of Health and National Health Insurance Bureau and integrated related literatures to understand the management strategies and responses of local hospitals under national health insurance policies and the economic, demographic and political environment. Results of the study will be provided for reference. Beside statistic data and literatures, strategy management concepts and theories were also adopted to clarify current policies of health insurance, reimbursement system and the situation of local hospitals to probe into the difficulties and possible solutions. Local hospitals were chosen to be the study subjects, and through SWOT Analysis, Poter¡¦s Five Force Analysis, Blue Sea Strategy and the findings from literature review, we found that (1)the financial gap of health insurance has transferred to medical organizations, especially local hospitals; (2)under global budget system, local hospitals have to increase income and decrease expenditures by transformation, running pay business or joint outpatient service; ¡]3¡^cost management is critical for local hospitals to establish internal strength; (4) referring to blue sea strategy to develop distinguished business and differential products can create niche for local hospitals to break through the bottleneck.

The objective of this thesis is the analysis of fiscal policy in the Russian Federation in 2008-2011. The thesis focuses on the beginning of the financial crisis in the Russian Federation, and then a period of economic recovery continued in the present. In the theoretical part is describing structure of the budget and its peculiar properties. Also discusses fiscal policy in the years 2008-2011. Significant emphasis is given to the analysis of changes in tax policy. The result of the analysis of fiscal policy is the evaluation of effect of the major fiscal measures during this period on the business sector.

This thesis deals with the control and audit of the state budget. The main objective is to evaluate the control and audit of state budget in the Czech Republic and provide recommendations. To achieve this objective, content analysis of literature and laws is done. Then based on the database of Budget Practices and Procedures Database, analysis of the responses of OECD countries is made. According to responses from the database, tables that compare the internal audit, external audit and performance audit carried out by the supreme audit institutions are compiled. From obtained knowledge and appreciation of the situation in the Czech Republic recommendations are proposed. In the area of internal audit is strictly necessary to separate the internal auditing function and increase the number of performance audits. In the area of external audit is essential to strengthen the powers of the Supreme Audit Office and legislatively adjust the annual audit of state budget. For the implementation of a performance audit carried out by the supreme audit institutions is necessary to eliminate the mistake in the law on the Supreme Audit Office, where it is not requirement of control effectiveness. It is necessary that the Supreme Audit Office began to conduct a performance audit. In the whole control system is necessary to increase the enforceability of the audit conclusions and ensure prosecution of those responsible for the shortcomings.

Cette thèse retrace les lignes directrices du projet de modernisation des systèmes budgétaires en Algérie s’inscrivant dans la lignée des réformes institutionnelles qui tendent à élever la budgétisation axée sur la performance au rang d’une norme internationale de bonne gouvernance. Son objectif est de faire ressortir d’abord, les considérable pris dans la mise en œuvre d’une réforme lancée quinze années auparavant.S’inscrivant dans le courant de la rationalité limité, ce travail énonce et valide l'hypothèse descriptive suivante : le passage à un système budgétaire axé sur la performance n’est possible que si les éléments de base du système budgétaire antérieur aient été consolidés. Le caractère aujourd'hui universel de la notion de performance doit amener à en considérer certains éléments et à faire abstraction de certains autres suivant un équilibre dynamique propre à chaque contexte, indépendamment des problématiques essentielles qui sont communes et dont la thèse s’efforce d’identifier.Cette thèse fonde finalement l'hypothèse transversale suivante : le contexte algérien actuel marqué par le caractère essentiellement rentier des finances de l’Etat est antinomique du thème de la performance. Tout en établissant le constat que la progression de la réforme se fait au cours d’un processus discontinu, l’étude conclut que la récente dégradation des finances de l’Etat achèvera sans doute d’ériger, la budgétisation axée sur la performance, en impératif économique et politique. / This thesis traces the guidelines of the modernization of budgetary systems project in Algeria in line with the institutional reforms which tend to rise the performance-based budgeting to the rank of an international standard of good governance. The aim of the work is, first, to outline the progress as well as the setbacks of the Algerian budget reform project, to highlight, then, its intrinsic practical and legal contradictions and to provide, finally, understanding and explanation about the considerable delay in implementing a reform initiated fifteen years previously. Enrolling in the limited rationality approach, this work outlines and validates the following descriptive hypothesis: the transition to a performance-based budget system is possible only if the basic elements of the previous budgetary system have been consolidated. Today, the universality of the performance concept must bring to consider certain elements and to ignore others following a dynamic equilibrium specific to each context, regardless of the essential issues that are common to which the thesis strives to identify.This thesis finally founds the following transverse hypothesis: the current Algerian context marked by the character essentially annuitant of the State's finances is antithetical to the performance’s theme. While establishing the observation that the progress of the reform is done during a discontinuous process, the study concludes that the recent deterioration of the State's finances will probably complete to erect performance-based budgeting as an economic and a political imperative.

我國政府預算採基金制，所有收入支出都透過基金處理，而基金依預算法規定又分為普通基金和特種基金兩類，前者為一般用途，後者為特殊用途。依預算法第四條的定義，特種基金依性質又分為營業基金、債務基金、信託基金、作業基金、特別收入基金、資本計畫基金六種，一般定義將營業基金及信託基金以外的四類基金統稱為「非營業基金」。非營業特種基金在設置之初都有其目的與必要性，但因種種原因，逐漸產生了基金設置浮濫、疊床架屋、功能不彰、作業效能欠佳、破壞財政統收統支之運作體制、影響國庫財務靈活調度等批評。 預算審議是立法權和行政權互動的結果，有時行政權對預算還具有更高的主導力，而政府總預算裡被視為管理效率最低、使用最混亂、淪為政府隱藏預算工具，同時資訊最不透明、最難以窺見財務全貌的就是非營業特種基金預算。由於非營業特種基金審議具有不同於一般預算的特殊性，本文即計劃透過對特種基金發展及編列過程、立法院預算審議程序及盲點的研究，了解立法院對特種基金監督機制的全貌，進而完成下列研究目的： （一）從分權監督、預算原理、政府財務管理、基金制度的發展與演變等，了解存在於政府預算編列與監督之間的總體問題。 （二）從特種基金的設置理論、特種基金與總預算的關係、政府對特種基金的需求與運用等，檢視特種基金運作的問題。 （三）研究非營業特種基金設置浮濫、疊床架屋、管理困難、規模不當、經營效率不彰、淪為隱藏預算之所、不符成本效益原則等的原因出在哪理？能否透過監督機制的強化而予以妥善解決？ （四）透過預算審議過程的解構，分析立法院特種基金監督機制的困境與難題，從而提出研究建議。 　　研究結果發現，就被監督者的行政部門而言，或出於有意的逃避監督，常發生財務資訊提供不足、或不提供財務以外的經營與績效資訊以供立法院審議的現象；有時則是出於無心的如使用過於專業複雜、過於本位的會計語言來編列特種基金預算的情況，無論何者，都已對監督構成了障礙。就身為主要監督單位的立法院而言，一方面要面對千方百計保障完整行政權的行政單位，一方面也受到自我能力不足、權力不完備的制約。就能力而言，立法委員少有會計專業能力，在責司龐雜、利益團體壓力遠大於專業預算審查使命、審查時間有限、調查權不完備等限制情況下，立法院對非營業特種基金的監督成果尚不能令人滿意。 為了改善立法院在監督品質低落，除了加強立法院預算中心之功能、增加國會專業助理、政黨內培育資深專業人才外，在預算審議流程之制度設計上應從取消多餘而無實益的審議程序、強化立法院在監督預算執行過程中的參與權。管理法規的層級應該提升為立法層次，透過特種基金管理法制化以制衡行政部門，同時應建立特種基金績效評估制度、立法促使財務資訊揭露透明化、適時修訂特種基金管理辦法及預算編列，如此才能真正落實特種基金監督與管理。 / The budget of Taiwan’s government uses a fund system, where all incomes and expenditures must be processed through funds. The Budget Act distinguishes two categories of funds, general funds for general purpose use and special funds for special purpose use. According to Article 4 of the Budget Act, special funds are further divided into six categories: enterprise funds, debt service funds, trust funds, operation funds, special revenue funds, and capital revenue funds. With the exception of enterprise funds and trust funds, all other funds a generally defined as non-profit funds. There are always specific goals and necessities at the origin of the creation of non-profit special funds. However, due to various reasons, these funds have been criticized for extravagant expenditures, unclear functions, and ineffectiveness, as well as for disrupting the income and expenditure mechanism of finances and having a negative influence on the financial management of the National Treasury. Budget approval results from the interaction between the legislative and executive powers, where the executive power sometimes yields greater influence. The budget for non-profit special funds is often criticized as yielding the lowest results, being badly use, being the government as a secret budget tool, and lacking transparency. Because the approval process of non-profit special funds is different from regular budgets, this paper will examine how special funds are created and what is the process for the approval of budget by the Legislative Yuan, as well as identify possible blind spots in order to gain a complete picture of the Legislative Yuan’s supervision mechanism for special funds. This research will achieve the following goals: 1. From the perspective of control through the separation of powers, budget principles, government financial management, and the evolution of the fund system, understand the problems that exist between the government’s budget planning and budget control mechanisms. 2. By examining the theory of special funds, the relationship between special funds and the general budget, as well as the need and use by the government of special funds, identify the problems inherent to the use of special funds. 3. Inquire into the causes behind the problems inherent to non-profit special funds, such as wasteful use, management difficulties, inappropriate size, lack of efficiency, insufficient transparency and poor cost-efficiency, and explore the possibility of improving the situation by strengthening supervision mechanisms. 4. Explore the structure of the budget approval process to analyze the difficulties faced by the Legislative Yuan in supervising special funds and provide recommendations. 　　This research found that the executive departments either deliberately avoid supervision by not providing sufficient financial information, or do not provide the Legislative Yuan with other information relevant to the administration and use of special funds. Sometimes, the involuntary use of too much accounting jargon by budget makers hampers the ability of legislators to understand and supervise budgets. No matter which circumstance, this creates many hurdles for supervision. As the most important supervising department, the Legislative Yuan must on one hand face numerous executive departments all intent in protecting their executive powers, and on the other hand must deal with restrictions such as limited capacity and limited powers. In terms of capacity, few legislators have professional accounting skills, they must also deal with limitations such as pressure from interest groups, limited time for budget review, and incomplete powers for investigation. As such, the result of supervision by legislators of non-profit special funds leaves to be desired. In order to improve the quality of supervision by the Legislative Yuan, apart from strengthening the central role of the Legislative Yuan in budgeting, increasing the number of professional staff, and cultivating professional staff within political parties, it is also necessary to reduce unnecessary procedures in the budget approval process, as well as strengthen the participative power of the Legislative Yuan in supervising the budget during its execution. The management of special funds should be regulated by law (and not by executive orders as is the present case) in order to balance the power of executive departments, and at the same time establish a system to evaluate the performance of special funds. The law will encourage greater financial transparency and allow the modification of the management process of special funds as well as the planning of budgets. This will facilitate the implementation of the supervision and management of special funds.

從實務面來看，總額支付制度（global budget）的施行絕非僅止於管制成本的手段，還必須觀照該管理的制度設計。畢竟制度不但能夠彙集各種資源，同時也成為資源使用的指標，影響行動者間的策略選項。另外，針對政策實施後的監控與評估檢討，也是修正制度與提升品質的反饋歷程。然而，學界與實務界在總額支付制度設計原則的研究卻十分有限，究其原因，重要的是主要集中於制度在實際的應用與效果，缺乏以一套適用的「方法」（methodology）來審視。誠如Elinor Ostrom所言，「政策分析家的工具箱有各式各樣的工具，但還缺乏一種具體明確的集體行動理論。」，共有資源管理的例子到處都有，但是分析家卻沒有很好的在理論上總結他們。他藉由制度分析與經驗實例，衍生出來的「制度設計原則」（Design principles），研究各種共有資源管理的問題：從不同類型的資源系統如灌溉系統、捕魚等自然資源或網路資源、財政預算等、到公共財制度研究等，都已經獲得豐碩的成果。本文的主要目標，就是在既有的理論基礎上，討論應用制度設計原則來進行「總額預算評估」的可能內容，並提出政策建議與後續研究的可能內容提出建議。 本文主要分為：（一）導論（二）文獻回顧與理論基礎（三）研究設計（四）中醫總額支付制度的演變（伍）中醫總額的自主管理（六）結論。希冀對學界或實務界在健保改革評估未來的發展，能有所啟發與助益。 / From the practice, global budget is not just the means to control cost, must also take the design of management into consideration. The institution not only can gather various kinds of resources, but also become the indexes, and influence the tactics among the persons who take action to select. Since a global budget married to fee-for-service payments directly analogous to a common-pool resources, we use a framework of design principles to explore the difference of outcomes of management, and to discuss the policy implications about institutional design and financial Incentives. Sincere as what Elinor Ostrom said, ' the policy analyst's box has many kinds of tools , but still lack a kind of concrete and clear collective action theory. ', example there are resource management in common everywhere, but it is the getting better to summarize they in theory. In addition, the “self-governing institutions” designed by each local medical association must be flexibly adapted to the context in which it is applied. To foster the cooperation among physicians, the medical associations of local level should also play the role to provide the institutional setting for collective participatory decision making. The medical associations of national level ought to change the financial incentives facing the physicians to induce the rational patterns of medical behavior so that the allocate efficiency of medical resource and effectiveness of global- budget management can be improved.

所有權結構、支付制度與競爭係影響醫院績效之關鍵因子，本研究援用相關文獻之發現，推論出三項因素對醫院績效之關係，並以我國獨特之總額預算制度為研究對象，蒐集、串連與合併不同來源之資料，實證檢視衝量競爭與所有權結構對醫院營運績效與醫療品質之聯合效果。 台灣於民國91年7月實施醫院總額預算制度後，浮動點值制度之設計為醫院間引入了衝量競爭(即虛假價格競爭)，而結算後之點值則係反映出醫院間衝量競爭後之結果，醫院除了需面對支付點值所致之財務衝擊外，尚須面對自全民健保實行後，備受醫院詬病之核減制度之衝擊，因此，本文首先嘗試估算醫院受到核減與支付點值所致之財務衝擊程度。無論是國外或國內之研究，對於不同所有權結構醫院之績效表現是否有差異性，一直無法獲得一致性之結論，除了納入營運效率之績效指標外，本研究亦採用疾病別與醫院層級別之醫療品質指標來檢視不同所有權結構醫院之績效表現。更以考量核減與支付點值所致之財務衝擊程度，取代目前文獻僅以總額前、後之二元變數，評估財務衝擊程度對營運效率、醫療品質與財務績效之影響。最後，則是檢視總額預算制度下，醫院受到之財務衝擊度是否會縮小不同所有權結構醫院之營運效率與醫療品質表現之差距。 實證研究發現，不同所有權結構醫院之營運效率並未有顯著差異，但不同所有權結構醫院在某些疾病別品質指標(子宮肌瘤切除手術之住院超過7日機率與再入院率)與醫院層級品質指標(院內感染率與淨死亡率)表現上則有差異性；且公立或非營利醫院受到核減與支付點值之財務衝擊高於私立醫院，因此不同所有權結構醫院之行為與績效存有某些差異性。台灣的醫院在總額預算制度下，若受到之財務衝擊程度愈大，其營運效率會變差、醫療品質也受到負面之影響、財團法人醫院之醫務利益率與稅後淨利率也會降低，但現金流量比則會增加，故財務衝擊愈大，醫院之績效愈低。若同時考量財務衝擊度對不同所有權結構醫院之營運效率與醫療品質之聯合效果後，可發現財務衝擊雖然不會縮小公立(或非營利)醫院與私立醫院營運效率之差距，卻縮小公立(或非營利)醫院與私立醫院醫療品質之差距，故以台灣資料可部分支持「不同所有權結構醫院績效差距縮小之因素係競爭力量之崛起」之論點。 / Hospital ownership, payment system and competition are all key drivers to influence hospital performance. This research infer and depict the association of these three drivers from the related literature and empirically examined the effects of fictitious price competition due to the floating point-value system and ownership on hospital operational performance and quality of care by combing and merging different sources of data. Deduction rate of claim and the floating point-value system are the two controversial debates to the payment system. I attempt to estimate hospital financial pressures as precipitated by deduction rate of claim and floating point-value system. To investigate whether for-profit, not-for-profit, and government hospitals differ in operating performance and quality of care, five diagnose-level and two hospital-level quality indicators are selected. Different from prior research, the financial pressure is captured by hospital data instead of a binary variable (pre and post global budget) and I examine the effect of financial pressure on hospital operational efficiency, quality of care and financial performance. Finally, we test whether differences in operational efficiency and quality care among hospitals with different ownership forms will mitigate or narrow, as hospital financial pressure increases. The results show that for-profit, not-for-profit and government hospitals are far more alike than different in operational efficiency, but ownership affects not only the rate of readmission and the rate of the length of stay larger than 7 days of uterine myomectomy, but also the hospital-level quality indicators: the rate of nosocomial infection and hospital mortality rate. I also find higher financial pressure incurred at government or not-for-profit hospitals than for-profits hospitals. Given my findings, we conclude that hospital ownership status affect performance in terms of quality of care and financial pressure from rate of deduction and float point-value system. The study shows that financial pressure adversely affects operational efficiency and quality of care. As not-for proprietary hospital financial pressure increases, the profit margin and net profit ratio will decrease, but the cash flow ratio will increase. Nonetheless, deduction rate of claim and global budget has a negative impact on hospital performance. This research further considers the joint effect of financial pressure on difference between quality of care and efficiency of for-profit hospitals and the other two types. My results indicate that hospital financial pressure mitigates the difference of quality of care between for-profit hospital and not-for profit (or government) hospitals, but does not narrow the difference in quality of care between for-profit hospital and not-for profit (or government) hospitals. This finding partly supports that increased competition should force not-for-profit (or governmental) hospitals to be increasingly similar to their for-profit counterparts.

Depuis son accession à l’indépendance, le Burkina Faso est à la recherche d’une politique publique de développement qui lui permette de sortir de son état de « sous-développement ». La politique budgétaire a, de ce fait, été instituée en catalyseur d’un développement économique et social durable. Mais les errements budgétaires des Gouvernements qui se sont succédé ont plutôt entraîné une triple crise : une crise de la dette, une crise des déficits publics et une crise économique. A compter des années 1990, le FMI et la Banque Mondiale sont intervenus, aux côtés des autorités burkinabé, dans le cadre d’une double assistance technique et financière afin de réformer, structurellement, la politique budgétaire. Cette intervention va s’installer durablement dans la politique interne burkinabé. En deux décennies, la politique des finances sera orientée au gré de la doctrine budgétaire et des priorités définies par le FMI et la Banque Mondiale : les programmes d’ajustement structurel, puis la politique de lutte contre la pauvreté vont tenter de réaliser les objectifs de croissance économique, puis de croissance économique et sociale, grâce à une réforme de la politique de dépenses budgétaires et de la politique de ressources budgétaires. Seulement, quelque soit l’objectif pris en considération, les résultats atteints restent bien éloignés des résultats escomptés en termes de restructuration de la dette, des dépenses et des ressources budgétaires. Cette dynamique de réformes permet néanmoins de s’interroger, au vu des expériences passées, sur le rôle à attribuer à l’Etat au Burkina Faso, à la politique budgétaire, au FMI et à la Banque Mondiale, aux institutions communautaires ouest-africaines dans le processus de développement que le Burkina Faso doit nécessairement relancer, afin que ces décennies de réformes ne soient pas considérées comme inutiles. / Since its independence, Burkina Faso is seeking public policy development that allows him to leave his state of "underdevelopment". Fiscal policy has, therefore, been established as a catalyst for sustainable economic and social development. But mistakes budget successive Governments have instead led to a triple crisis: a debt crisis, a crisis of deficits and an economic crisis. Beginning in the 1990s, the IMF and the World Bank intervened alongside Burkinabe authorities, within a double technical and financial assistance to reform structurally fiscal policy. This intervention will settle permanently in the internal politics of Burkina Faso. In two decades, finance policy will be geared to suit the budget doctrine and priorities defined by the IMF and the World Bank: the structural adjustment programs and the political fight against poverty will try to achieve the objectives of economic growth, and economic growth and social reform through policy and budgetary spending policy of budgetary resources. But whatever the goal under consideration, the results achieved are far removed from the expected results in terms of debt restructuring, expenditure and budgetary resources. This dynamic reforms can nevertheless wonder, in view of past experience, the appropriate role for the state in Burkina Faso, fiscal policy, the IMF and the World Bank, the Community institutions in West Africa the development process as Burkina Faso must necessarily raise, so that decades of reforms are not considered necessary.