Através do presente estudo analisou-se as decisões judiciais proferidas pelos Tribunais Superiores do Brasil - Supremo Tribunal Federal (STF) e Superior Tribunal de Justiça (STJ) - acerca dos conflitos entre usuários e operadoras de planos de saúde, a fim de verificar se nos julgamentos tem sido considerada a necessidade de preservação do direito à saúde. Na Parte I foram apresentados os pressupostos de compreensão do setor de planos de saúde, colocando-se à disposição informações sobre as denominações e classificações adotadas, histórico de formação e atual configuração. Ainda na primeira parte dissertou-se sobre o foco escolhido para a análise jurisprudencial: o direito à saúde. Evidenciou-se o processo histórico de reconhecimento dos direitos humanos e como o direito à saúde nele se inseriu, a natureza desse direito e sua consagração na legislação internacional e brasileira. Considerada a abordagem contratual que é dada aos planos de saúde, também se discorreu, ainda que brevemente, sobre o Código de Defesa do Consumidor (Lei nº 8.078/90) e a Lei de Planos de Saúde (Lei nº 9.656/98). A pesquisa jurisprudencial, apresentada nos capítulos da Parte II, abrangeu decisões sobre conflitos entre usuários e operadoras de planos de saúde disponíveis nos endereços eletrônicos dos Tribunais Superiores até 3 de junho de 2008 - data em que a Lei de Planos de Saúde completou 10 anos. Verificou-se que o STF não analisou o mérito dos recursos que lhe foram apresentados. A fundamentação adotada para tanto tem relevância na análise do impacto das decisões dos Tribunais Superiores na efetivação do direito à saúde em planos de saúde, mas prejudicou análises complementares. Assim sendo, no capítulo 5 as decisões do STJ e do STF foram analisadas no que diz respeito ao direito à saúde, e ao capítulo seguinte reservou-se a apresentação de aspectos complementares dos Recursos Especiais (STJ), como a natureza dos conflitos, a autoria das ações e os principais procedimentos, insumos e doenças negados aos usuários / Health insurance at Justice: is the right to health being effectived? studies how the Brazilian Superior Courts judge conflicts between health insurance companies and their users/clients. The objective of the study is to investigate whether and how the right to health takes part in the sentences. In the first part of the study the specific characteristics of the health insurance sector are introduced, including its development and its nowadays configuration and data. In the second part the judments of the Superior Courts (Superior Tribunal de Justiça and Supremo Tribunal federal) are presented and analysed.

A assimetria de informação no sistema de saúde é um tema que ultrapassa o interesse apenas das empresas operadoras de seguro de saúde, de políticas públicas e de pesquisa acadêmica. O presente estudo analisa como os contratos de cosseguro influenciam os fenômenos do risco moral e da seleção adversa presentes nos planos de saúde e sua relação com a demanda de serviços médicos. Neste contexto, analisar a assimetria de informação no sistema de saúde se torna relevante por oferecer uma resposta consistente, que poderá embasar tanto as políticas públicas, quanto a forma de comercialização dos planos pelas empresas. Esse trabalho, a partir da Pesquisa Nacional por Amostra de Domicílios - PNAD 2003, procura observar a eficiência do contrato cosseguro como um mecanismo de mitigação de assimetria de informação, ou seja, excluídos os efeitos dos riscos associados ao indivíduo, se a diferença de contrato altera o comportamento dos agentes. Para atingir esse resultado foi proposto um método para testar a assimetria de informação utilizando o método de Monte Carlo. Os resultados sugerem que os contratos de cosseguros foram eficientes nos planos individuais, enquanto nos planos coletivos sua influência pode ser descartada. Por fim, o trabalho aponta que é mais eficiente, pelo bemestar social, a utilização de cosseguro para os contratos individuais, enquanto para os contratos coletivos são mais eficiente os contratos sem cosseguro. / Asymmetric information in the health care system is a topic of interest for medical insurance, policy makers and scholars. This research analyses how the contracts of coinsurance motivate the moral hazard and adverse selection phenomenon and consequences in medical services demand. In this context, the analysis of asymmetric information in the health care system provides support for the design of public policy and insurance plans. This research aims to estimate a structural model of health insurance and health care choices, using the 2003 National Household Sample Survey PNAD. It tested whether coinsurance contracts can work as efficient mechanisms to reduce risks related to asymmetric information. A methodological procedure using the Monte Carlo method was proposed to test for asymmetric information issues. The research suggests that coinsurance contracts were beneficial for individual plans, from a social welfare perspective. For the group plans, the benefit was not supported

University of Macau / Faculty of Social Sciences. / Department of Government and Public Administration

Submitted by PPG Economia do desenvolvimento (economia-pg@pucrs.br) on 2018-05-14T20:42:09Z No. of bitstreams: 1 ANNE_JULISSA_ADUBER_PENALOZA_TES.pdf: 3031751 bytes, checksum: 27dc405ec8dc4ef1271f4c34d565e5c6 (MD5) / Approved for entry into archive by Sheila Dias (sheila.dias@pucrs.br) on 2018-05-18T15:00:23Z (GMT) No. of bitstreams: 1 ANNE_JULISSA_ADUBER_PENALOZA_TES.pdf: 3031751 bytes, checksum: 27dc405ec8dc4ef1271f4c34d565e5c6 (MD5) / Made available in DSpace on 2018-05-18T15:11:47Z (GMT). No. of bitstreams: 1 ANNE_JULISSA_ADUBER_PENALOZA_TES.pdf: 3031751 bytes, checksum: 27dc405ec8dc4ef1271f4c34d565e5c6 (MD5) Previous issue date: 2017-10-03 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES / This thesis is composed of three articles on Health Economics. The first document seeks to analyze the possible spatial integration of the network of public hospitals in Colombia, with the aim of analyzing whether there is efficiency when remitting patients according to the type of care demanded in the hospital. Based on the estimation of a spatial panel model, we analyzed the total of hospitals that make up the public offer system, concluding that although there may be a certain degree of transfer in patient care, it is very low for the case of general medicine, given that the spatial coefficient of the SDM model, rho is less than one. Once the analysis for the static model was estimated, the dynamic SAR and SDM model was estimated, a dynamic model was estimated that decomposed the effects in direct and indirect, where it was evidenced that there is a long-term spatial distribution effect for the attention of appointments of general medicine determined by the number of health care personnel of the 4 closest hospitals, however the presence of transshipments was not found in the short term in general medical care among the hospitals of the public network, since these are the ones that behave as institutions providing basic services, without having a trained staff that allows better care from the development of better medical practices. The same article calculates the SDM, SAR, SAC models for highly complex hospitals, having as dependent variable the number of surgeries performed with a normalized distance matrix of 8 neighbors, concluding that the number of emergencies attended by the hospital affects negative in the total of surgeries practiced, that is to say, the hospitals of high level of complexity carry out in their majority programmed surgeries, nevertheless a change in the total of emergencies. In order to control the existence of random spatial effects in the error, the model is estimated. GSPRE shows that there is a spillover effect that varies little in the time given by the coefficient lambda = 0,10, which is statistically significant but small , and that if there are shocks over time that significantly modify the behavior between hospitals. This type of variation is related as it is expressed cite baltagi2013generalized with technological shocks, changes in the facilities of hospitals that allow to significantly change the capacity to perform surgeries. The second article analyzes decentralization in the health system, studying one of the main objectives in public policy: the prevention of diseases, analyzing the effectiveness of the program in performing preventive cytopathological exams in women, given the availability of resources in the basic care teams located in all the municipalities of Brazil. Based on the analysis of the National Melhoria do Acceso e da Qualidade de Aten??o B?sica -AMPprogram, a factorial analysis is performed that calculates the covariances between the personnel, medical and physical supplies available in the equipment, as well as features such as race, income, literacy level, among others, the decision of women to undergo the cytopathological examination, a model is realized that includes a system of structural equations. It concludes that decentralization is due more than to a system formed in a correct way according to national and international parameters, to a management of the bureaucrats, as it was shown, in the states where there is a deficit or an adequate number of health posts , the estimate had positive coefficients, but this beyond the flow of resources, depends on the political will of each one of the government spheres to increase the number of health establishments or health programs. In this way, and in family health programs such as the performance of cytopathological tests, it is taking place in the basic care network in Brazil, in compliance with the Health Pact established for Brazil. Finally, the analysis of the demand for private health plans is made from different variables of individual, family, social, economic and geographical characterization of individuals and units of family consumption or Brazilian households, based on a logit model. It allows determining that individuals of the amarela race have the highest probability of choosing to demand a private health plan in Brazil, specifically in the North, South and Southeast regions of the country. Thus, in the Southeastern region of Brazil, at a level of significance of 1% the probability of demanding private health insurance is greater for people of that skin color or race, an additional control is created: division by range of monthly per capita income level; In this way, it is observed how the possibility of demanding private health plans varies according to the race declared by the individuals associated with the level of income received in per capita terms by the Brazilian family consumption units, which reflects that with a per capita income monthly of 200 reais, regardless of the declared race, all individuals have the same probability of demanding a private health plan in Brazil. / Esta tesis esta compuesta por tres art?culos sobre Econom?a de la Salud. El primero documento busca analizar la posible integraci?n espacial de la red de hospitales p?blicos en Colombia, con el objetivo de analizar si existe eficiencia la momento de remitir los pacientes de acuerdo a el tipo de asistencia demandada en el hospital. A partir de la estimaci?n de un modelo de panel espacial, se analiz? la el total de hospitales que componen el sistema de oferta p?blica, concluyendo que a pesar de que puede existir cierto grado de transferencia en la atenci?n de pacientes es muy baja para el caso de medicina general, dado que el coeficiente espacial del modelo SDM, ? es inferior a uno. a vez realizado el an?lisis para el modelo est?tico se estimo el modelo din?mico SAR y SDM, se estimo un modelo din?mico que descompusiera los efectos en directos e indirectos, donde se evidencio que existe un efecto de distribuci?n espacial a largo plazo para la atenci?n de citas de medicina general determinado por el n?mero de personal asistencial de los 4 hospitales m?s cercanos sin embargo no se encontr? la presencia de transbordamientos en el corto plazo en la atenci?n de medicina general entre los hospitales de la red p?blica, dado que estas que estos se comportan como instituciones de prestaci?n de servicios b?sicos, sin disponer de un personal capacitado que permita una mejor atenci?n a partir del desarrollo de mejores practicas medicas. El mismo articulo calcula los modelos SDM,SAR,SAC para los hospitales de alta complejidad, teniendo como variable dependiente el n?mero de cirug?as practicadas con una matriz de distancia normalizada de 8 vecinos, concluyendo que el n?mero de urgencias atendidas por el hospital incide de manera negativa en el total de cirug?as practicadas, es decir, los hospitales de nivel alto de complejidad realizan en su mayor?a cirug?as programada, no obstante un cambio en el total de emergencias. con el prop?sito de controlar la existencia de efectos espaciales aleatorios en el errores se estimo el modelo GSPRE muestra que existe un efecto spillover que varia poco en el tiempo dado por el coeficiente ? = 0, 10 , que es estad?sticamente significativo pero peque?o, y que si existen shocks en el tiempo que modifican de manera significativa el comportamiento entre los hospitales. Este tipo de variaciones esta relacionado tal como lo manifiesta [21] con shocks tecnol?gicos, cambios en las instalaciones de los hospitales que permitan var?en de manera significativa la capacidad de realizar cirug?as. El segundo articulo analiza la descentralizaci?n en el sistema de salud, estudiando uno de los principales objetivos en la pol?tica p?blica: la prevenci?n de enfermedades, analizando la efectividad del programa en la realizaci?n de examenes citopatologicos preventivos en las mujeres, dada la disponibilidad de recursos en los equipos de atenci?n b?sica situados en todos los municipios de Brasil. A partir del an?lisis del programa Nacional de Melhoria do Acceso e da Qualidade de Aten??o B?sica ?PMAQ-, se hace un an?lisis factorial que calcula las covarianzas entre los insumos de personal, m?dicos y fisicos disponibles en los equipos, as? junto con caracter?sticas como la raza, ingresos, nivel de alfabetizaci?n, entre otras, la decisi?n de las mujeres de realizarse el examen citopatol?gico, se realiza un modelo que comprenda un sistema de ecuaciones estructurales. Se concluye as? que la descentralizaci?n se debe m?s all? que a un sistema conformado de manera correcta seg?n par?metros nacionales e internacionales, a una gesti?n de los bur?cratas, tal como se mostr?, en los estados donde hay d?ficit o un adecuado numero de puestos de salud, la estimaci?n tuvo coeficientes positivos, pero esto m?s all? del flujo de recursos, depende de la voluntad pol?tica de cada una de las esferas del gobierno para aumentar el numero de establecimientos de salud o de programas de salud. De est? manera, y en programas de salud familiar como la realizaci?n de examenes citopatologicos, se esta dando en la red de atenci?n b?sica en Brasil, dando cumplimiento al Pacto por la salud establecido para Brasil. Por ultimo se realiza el an?lisis de la demanda de planes de salud privados a partir de diferentes variables de caracterizaci?n individual, familiar, social, econ?mica y geogr?fica de los individuos y unidades de consumo familiar u hogares brasileros, a partir de un modelo logit. La permite determinar que los individuos de raza amarela, poseen la probabilidad m?s alta de elegir demandar un plan de salud privado en Brasil, espec?ficamente en las regiones Norte, Sur y Sureste del pa?s. De modo tal que en la regi?n sureste de Brasil, a un nivel de significancia del 1% la probabilidad de demandar un aseguramiento privado en salud es mayor para las personas de dicho color de piel o raza, se crea un control adicional: divisi?n por rango de nivel de renta per c?pita mensual; de esta manera se observa c?mo var?a la posibilidad de demandar planes de salud privados de acuerdo a la raza declarada por los individuos asociada al nivel de ingresos percibidos en t?rminos per c?pita por las unidades de consumo familiar brasileras lo cual refleja que con una renta per c?pita mensual de 200 reales, independientemente de la raza declarada, todos los individuos tienen la misma probabilidad de demandar un plan de salud privado en Brasil.

Made available in DSpace on 2015-12-03T18:35:28Z (GMT). No. of bitstreams: 1 Isabel_Cristina_Barbosa_Pinheiro.pdf: 2622902 bytes, checksum: 749431cab43b468b437e27cb0f5a0567 (MD5) Previous issue date: 2014-01-24 / The Brazilian public health system is deficient and doesn't fully meet the needs of the population. As a result, the private health care market has grown in recent years, which has changed the role of the state from executive to regulator of that sector. Regulation includes tackling the economic and financial issue. Our study aimed to identify the behavior of financing strategies adopted by medical cooperatives and group medicines to meet the regulatory benchmarks of the supplementary health care sector in Brazil. The survey results show that the mandatory Guaranteeing Assets (Ativos Garantidores, AG), 1st regulatory moment, resulted in a significant increase of both the overall and the long term indebtedness indexes, which reveals the use of Third-party capital instead of Equity capital. Only the Medical Cooperatives featured increased Overall Indebtedness, which means that the Medical Cooperatives, unlike Group Medicines, are capitalized by third party funds rather than by Equity Capital. Both modalities adopted the strategy of increasing their long-term debt and reducing their short term debt (debt composition). With the introduction of the Health Guarantor Fund (Fundo Garantidor da Sa??de, FGS), 2nd regulatory moment, the Overall and Current Liquidity indexes decreased, showing that the goal of the FGS program to reduce financial guarantees and to improve working capital wasn't met. Medical Cooperatives managed to reduce their overall debt, whereas the overall debt of Group Medicines increased. We conclude that there was a balance between the Indebtedness indexes and Liquidity over the period and that operators who wish to remain in the market must comply with the rules, adapting and improving the quality of their management / A rede p??blica de sa??de no Brasil ?? prec??ria e n??o atende de forma plena ??s necessidades da popula????o. Consequentemente, o mercado privado de assist??ncia ?? sa??de tem crescido nos ??ltimos anos e com isso a fun????o do Estado vem se alterando, passando de executor para regulador deste setor de atividade. Um alvo da regula????o ?? a quest??o econ??mico-financeira. Nesse sentido, este trabalho tem como objetivo identificar o comportamento das estrat??gias de financiamento adotadas pelas cooperativas m??dicas e medicinas de grupo frente aos marcos regulat??rios do setor de sa??de suplementar no Brasil. Os resultados da pesquisa indicam que com a obrigatoriedade dos Ativos Garantidores - AG, 1?? momento regulat??rio, os ??ndices de Endividamento, tanto geral quanto de longo prazo tiveram um aumento significativo, o que indica a utiliza????o de Capital de Terceiros ao inv??s do Capital Pr??prio. Observou-se que apenas as Cooperativas M??dicas apresentaram um aumento no Endividamento Geral. Isso indicou que as Cooperativas M??dicas, diferentemente, das Medicinas de Grupo, se capitalizaram com recursos de terceiros ao inv??s do Capital Pr??prio. Notou-se que ambas as modalidades adotaram a estrat??gia de aumentar a d??vida de longo prazo e reduzir as de curto prazo (composi????o do endividamento). Com a institui????o do Fundo Garantidor da Sa??de - FGS, 2?? momento regulat??rio, os ??ndices de Liquidez Geral e Corrente diminu??ram, indicando que a proposta do programa FGS, de reduzir as garantias financeiras e melhorar o capital de giro, n??o ocorreu. Observou-se que para as Cooperativas M??dicas o endividamento geral diminuiu e em contrapartida para as Medicinas de Grupo aumentou. Contudo, conclui-se que houve um equil??brio entre os ??ndices de Endividamento e Liquidez ao longo do per??odo e que para as operadoras se manterem no mercado ter??o que atender as regras, adaptando-se e melhorando a qualidade da sua gest??o

O presente estudo tem como objetivo analisar a lucratividade dos clientes em uma operadora de saúde do segmento de baixo custo no Brasil. O mercado de saúde suplementar enfrenta inúmeros desafios para prosperar. Com a expansão nos últimos anos da classe média brasileira - a classe C - houve um aumento da demanda por serviços de planos de saúde privados de baixo ticket-médio. Foi realizada uma revisão da literatura, para embasar os princípios de modelos de negócios, a análise de lucratividade do cliente e a segmentação de clientes em uma operadora de saúde. O método utilizado foi um estudo de caso único, com pesquisa de dados de ordem qualitativa e quantitativa. Foram realizadas algumas entrevistas com os três principais executivos da operadora investigada, com o intuito de compreender o modelo de negócio construído e todos os seus diferenciais e inovações que garantiram seus resultados superiores à média do setor. Foram coletados dados contábeis, bases de receita e custo por beneficiário para análise quantitativa do resultado. Foi apresentado o modelo de negócio do estudo de caso investigado, bem como avaliada a lucratividade de clientes da operadora. Iniciou-se por uma análise quantitativa geral de variação contábil, com aprofundamento de análises na base de receita e custo de clientes, por sinistralidade, margem de contribuição absoluta e demais parâmetros, além da aplicação do conceito de CLV - Customer Lifetime Value. Ao analisar os resultados associados à avaliação da lucratividade, foram constatadas ações que pudessem ser tomadas para a melhora da mensuração do resultado final. O final das análises por cliente e por CLV se concentraram em grandes clientes corporativos, pois estes representam mais de 70% da carteira da operadora investigada. A conclusão apresentada foi a seguinte: para aumentar a margem de lucro absoluta bruta (R$) do negócio, ao subtrair as despesas assistenciais das receitas, deve-se segmentá-la por tipo de cliente e encontrar a margem de contribuição de cada. Na sequência, é necessário reajustar os clientes com margem de contribuição negativa, logo, obtém-se o maior resultado possível em termos de margem bruta total absoluta. Porém, mesmo para os clientes com margem de contribuição positiva, deve-se aprofundar sua análise de valor no tempo com o conceito do CLV. Verificou-se que clientes de margem positiva podem apresentar um CLV negativo para o mesmo período analisado. Esses clientes não devem ser desconsiderados, porque afetariam o resultado final, porém devem ser destacados na gestão, para serem mais bem renegociados numa revisão de valores contratuais e aumento do seu ticket-médio. / This study aims to analyze the profitability of customers in a health maintenance organization (HMO) of low-cost segment in Brazil. The health insurance market faces numerous challenges to thrive. With the expansion in recent years of Brazilian middle class - the class \'C,\' there was an increase in demand for private health plans to low-average ticket services. A literature review was conducted to support the principles of business models, customer profitability analysis and customer segmentation in a health provider. The method used was a single case study, with qualitative and quantitative research data. Interviews were conducted with the top three executives in the investigated company, to understand the business as presented, as well as the analysis of HMO\'s customer profitability. It´s began as a general quantitative analysis of accounting variation, with deeper analysis on revenue and cost base per members, by MLB (Medical Loss Benefit), gross margin and other parameters, in addition to applying the concept of CLV - Customer Lifetime Value. When analyzing the results associated with the evaluation of profitability, actions were found that could be taken to improve the measurement of the final result. The end of the analysis by customer and by CLV was focused on large corporate clients, as they represent more than 70% of the investigated portfolio. The conclusion was presented: to increase model built and all its advantages and innovations that have ensured their results above the industry average. We collected accounting data, revenue and cost base by membership for quantitative analysis. The business model of the investigated case study the margin of gross profit absolute (R$) in the business, by subtracting the medical cost from revenues, it should be segmented by customer type and find the contribution margin of each one. Further, it should be reajusted all customers with a negative contribution margin, so it could be obtained the highest possible result in terms of absolute gross margin. But even customers with positive contribution margin, should be deepen in their analysis of value in time with the concept of CLV. It was found that positive margin accounts may have a negative CLV for the same reported period. Those customers should not be disconsidered, because affect the final result, but should be highlighted in the management review, to be better renegotiated as contract values and increased its ticket-average.

5 Abstract Legal regulation of healthcare in the Czech Republic The subject matter of this thesis is legal analysis of provision of healthcare in the Czech Republic and outline of basic problems of provision of healthcare, including proposals for their possible solution and comparison with Supreme Court and Constitutional Court jurisprudence. The thesis deals not only with the specific legal regulations in which the provision of healthcare is regulated, but also with the interpretation of their content, as well as with the legal relations between the entities involved in the provision of healthcare. In addition, the thesis discusses the introduction of the electronization of healthcare, which has the potential to improve the healthcare system in the Czech Republic and make the provided healthcare better, cheaper and more accessible. The thesis is divided into five chapters, which are further subdivided into subchapters. The first chapter is about the basic sources of legal regulation of healthcare at international, European and national level. The second chapter deals with the methods of financing the provided healthcare with a particular emphasis on the public health insurance system in the Czech Republic. Subsequently, chapter three deals more closely with healthcare itself and with the interpretation of...

In most markets, competition induces efficiency by ensuring that goods are priced according to their marginal cost. This is not the case in health insurance markets. This is due to the fact that the cost of a health insurance policy depends on the characteristics of the consumer purchasing it, and asymmetric information or regulation often precludes an insurer from matching the price an individual pays to her expected cost. This disconnect between cost and price causes inefficiency: When the premiums paid by consumers do not match their expected costs, consumers may sort inefficiently across plans. In this dissertation, I study the effects of policies used to alleviate selection problems. In Chapter 1, I develop a model to study the effects of risk adjustment on equilibrium prices and sorting. I simulate consumer choice and welfare with and without risk adjustment in the context of a Health Insurance Exchange. I find that when there is no risk adjustment, the market I study unravels and everyone enrolls in the less comprehensive plan. However, diagnosis-based risk adjustment causes over 80 percent of market participants to enroll in the more comprehensive plan. In Chapter 2, we study an unintended consequence of risk adjustment: upcoding. When payments are risk adjusted based on potentially manipulable risk scores, insurers have incentives to maximize those risk scores. We study upcoding in the context of Medicare, where private Medicare Advantage plans are paid via risk adjustment but Traditional Medicare is not. We find that when the same individual enrolls in a private plan her risk score is 5% higher than if she would have enrolled in Traditional Medicare. In Chapter 3, we study two forms of insurance for insurers: Reinsurance and risk corridors. Protecting insurers from risk can lower prices and improve competition by inducing entry into risky markets. It can also induce inefficiencies by causing insurers to manage risk less carefully. We use simulations to compare the power of reinsurance and risk corridors to protect insurers against risk while limiting efficiency losses. We find that risk corridors are always able to limit insurer risk with the lowest efficiency cost.

伴隨著改革開放開始的中國醫療改革由於受到過度市場化的影響，一直在質疑聲中前行。進入21世紀，社會醫療保障制度改革標誌著中國醫改「健康公平」之路的回歸。然而，在公平正義不斷被強調的口號背後，對「健康公平」的理論界定與實證研究仍然相對匱乏。 / 本研究從「弱者優先」的社會公義理論出發，重新將「健康公平」理論界定為「基於社會公義的健康平等」。研究員立於足后實證主義研究範式，綜合運用質化與量化研究方法，結合一手與二手數據分析，以浙江省為研究場域，探索以社會醫療保險改革為核心的醫療福利制度改革，對老年人「健康公平」所造成的影響。最終，確立了「底層健康公平」的價值選擇，並發展了多元健康公平的理論框架。 / 透過量化研究的主要發現，研究員的結論是要將健康公平問題從「機會公平」視角轉換為健康「結果公平」。另一重要的結論是不要單一關注社會醫療保險改革覆蓋面的擴大，更應關注不同保險項目之間福利待遇的公平性。透過多元線性回歸分析，研究員發現了醫療保險改革之後影響老年人健康水平的顯著因素：微觀層面的社會經濟地位與慢性病特徵，宏觀層面的保險因素與中觀層面的社會支持網絡。質化研究的採用將「健康公平」的討論從關注客觀的「健康結果」擴展為利益相關者主觀的公平性體驗。質化研究補充了政策制定者、基層醫生與弱勢老年人各自對「健康公平」的理解，進一步回答了「什麽是健康公平」，確立了本研究的底層視角。 / 混合研究進一步回答了社會醫療保險改革對老人「健康公平」的影響：雖然醫療保險改革提高了老人的「機會公平」，但這只是形式公平，改革在推動「過程公平」與「結果公平」這些實質公平的維度尚待探索。在醫療保險改革之後，進一步的路徑分析評估了「醫療服務使用」作為mediator的作用，呈現了與「健康水平」之間的負向因果關係。交互作用分析表明，如若改變弱勢老年人社群在「健康公平」中的弱勢地位，就需要社會醫療保險改革調節「醫療服務使用」與「健康水平」的關係；且澄清了不同社會醫療保險項目作為moderator的差別：城鎮職工基本醫療保險可以改善使用較多醫療服務的老人的健康水平，而新型農村合作醫療則起到相反的作用。在這些變量之間的關係背後，站在「弱者優先」的底層立場上，深入的質化研究補充了社會醫療保險改革對弱勢老人接受醫療服務與享受醫療福利待遇「過程公平」的缺失與「結果公平」的不足。 / 結合以上量化與質化研究發現，本研究識別出了「健康公平」多維度的影響因素（經濟地位、健康地位、社會關係網絡、身份地位、福利地位），建立了包括機會、結果和過程公平在內的多元的健康公平理論框架。並且綜合討論了「健康公平」理論的反思與重構，混合研究方法在評價醫療保障改革公平性實證研究中運用的可行性，並且倡導在政策制定中改變福利觀念，提出了如何進行公平的「全民醫保」政策改革，以及如何實現「以社區為中心的綜合健康服務與長期照顧體系」的政策創新。 / Along with the reform and opening up, the health reform in China had been continously challenged due to its excessive marketization. As the pioneer of a new round of health reform since 21st century, social health insurance reform reiterated ‘health equity’. Nevertheless, neither theoretical nor empirical studies were abundant behind the slogans for the advancement of equity and justice. / This thesis began with theory of social justice based on ‘give priority to the disadvantaged group’, redefining the concept of ‘health equity’ by ‘health equality on the basis of social justice’. Adopting of the paradigm of post-positivism, researcher chose quantitative-and-qualitative mixed method, and combined analysis of primary data and secondary data. This study has been located in Zhejiang province, intending to explore the impacts of health insurance reform along with health welfare system changes on health equity among the elderly. Researcher finally adopted the value choice of health equity for vulnerable groups, and developed a multi-dimension theoretical framework of ‘health equity’. / From the quantitative research findings, researcher modified the theory of health equity from concerning ‘equal opportunity’ to ‘equal outcome’. This research also contributed to a transition of health insurance studies from emphasis on expansion of ‘insurance coverage’ to the concerns with unequal benefit packages between different social insurance schemes. Multiple linear regression demonstrated significant predictors of older adults’ health outcome after health insurance reform, composing of socio-economic status and chronic disease in the micro-level, health insurance in the macro-level, and social support in the meso-level. Simultaneously, qualitative research explained diversive understandings of ‘health equity’ among policymakers, doctors who provide primary care and vulnerable older adults. The crucial question of ‘what is health equity’ has been answered, and that the ‘give priority to the disadvantaged group’ standpoint being reaffirmed. / Mixed method study further answered the research question of ‘what is impacts of health insurance reform on the health equity among the elderly’: Although health reform improved ‘opportunity equity’ for older adults as a kind of ‘form fairness’, it was still expected to explore other dimensions of ‘essential fairness’, such as ‘process equity’ and ‘result equity’. After health insurance reform, researcher employed path analysis to test mediator effects of ‘healthcare utilization’, which demonstrated negative causal relations with ‘health outcome’. Interaction effect analysis manifested a moderating effect of health insurance reform adjusting the relationship between ‘healthcare utilization’ and ‘health outcome’ with an attempt to improve social status for disadvantaged older groups. Interaction effects of different insurance schemes have been clarified as well: The Basic Medical Insurance for Urban Employees could improve health outcome of the elderly who use more health care services, whereas the New Rural Cooperative Medical Scheme played an opposite function. Under the background of these relations between variables, being standfast in vulnerabe groups’ stand, researcher adopted qualitative data to complement quantitative findings: The lack of ‘process equity’ and the short of ‘outcome equity’ during the process of interpreting accessibility to health care services and utilization. / In this dissertation, researcher also synthetically combined findings in quantitative and qualitative research, identified multiple predict factors of ‘health equity’ (economic status, health status, social networks, identity status and welfare status). All of above mentioned factors jointly composed and enriched multi-dimensional ‘health equity’ theoretical framework (including equitable opportunity, outcome and process). It also profoundly rethought and reconstructed ‘health equity’ theory, and evaluated efficiency and effectiveness of health insurance reform by using mixed research methods. Researcher advocated a transition of welfare ideology in the process of policy making, and recommended an ‘universal health insurance’ reform based on health equity, then initiated a ‘home and community based comprehensive health and long-term care service’ system. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / 劉曉婷. / "2013年3月". / "2013 nian 3 yue". / Thesis (Ph.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 386-422). / Abstract in Chinese and English. / Liu Xiaoting. / 論文摘要 --- p.I / Abstract --- p.III / 致謝 --- p.VI / Chapter 第一部份 --- 研究背景 --- p.1 / Chapter 第一章 --- 導論 --- p.2 / Chapter 第一節 --- 研究的緣起 --- p.2 / Chapter 一、 --- 醫療改革中的公平性失守 --- p.3 / Chapter 二、 --- 醫改糾偏：重建社會公平的改革共識 --- p.6 / Chapter 三、 --- 聚焦老年人：醫療保障改革中的弱勢社群 --- p.10 / Chapter 四、 --- 研究場域：浙江醫改之路 --- p.12 / Chapter 第二節 --- 研究問題的提出 --- p.16 / Chapter 第三節 --- 研究的目標 --- p.19 / Chapter 一、 --- 從理論上對「健康公平」的界定與發展 --- p.19 / Chapter 二、 --- 從實證研究中識別「弱勢老年人」的社會結構、關係網絡與疾病風險特徵 --- p.20 / Chapter 三、 --- 通過混合研究方法探索醫療保險改革與老人健康公平的因果關係 --- p.21 / Chapter 四、 --- 探索建立「健康公平」研究的理論框架 --- p.21 / Chapter 第四節 --- 本文的結構 --- p.24 / Chapter 第二部份 --- 研究準備 --- p.27 / Chapter 第二章 --- 文獻回顧 --- p.28 / Chapter 第一節 --- 平等與公平 --- p.28 / Chapter 一、 --- 平等的主體與客體 --- p.29 / Chapter 二、 --- 公平的價值選擇 --- p.35 / Chapter 第二節 --- 基於社會公義的健康公平 --- p.41 / Chapter 一、 --- 健康公平的界定 --- p.41 / Chapter 二、 --- 健康公平的實現 --- p.48 / Chapter 三、 --- 底線公平 --- p.53 / Chapter 第三節 --- 醫療保險、醫療服務使用與健康水平的關係 --- p.58 / Chapter 一、 --- 文獻回顧與批評 --- p.58 / Chapter 二、 --- 對老年人健康水平認識的發展 --- p.64 / Chapter 第四節 --- 影響健康公平的社會決定因素 --- p.69 / Chapter 一、 --- 社會結構因素 --- p.69 / Chapter 二、 --- 社會網絡因素 --- p.78 / Chapter 第五節 --- 中國社會醫療保險制度改革 --- p.87 / Chapter 一、 --- 中國傳統醫療保障制度及其缺陷 --- p.87 / Chapter 二、 --- 社會醫療保險的道路選擇與發展 --- p.91 / Chapter 三、 --- 醫療保障制度改革對弱勢社群的排斥 --- p.102 / 本章小結 --- p.107 / Chapter 第三章 --- 方法論與反思 --- p.109 / Chapter 第一節 --- 研究範式：對後實證主義的理解 --- p.109 / Chapter 一、 --- 範式與範式轉移 --- p.109 / Chapter 二、 --- 證偽與後實證主義的運用 --- p.112 / Chapter 三、 --- 研究方法的層次與後實證主義的適用性 --- p.116 / Chapter 第二節 --- 混合研究方法 --- p.118 / Chapter 一、 --- 量化與質化研究各自的優缺點 --- p.118 / Chapter 二、 --- 選擇混合研究方法的理由 --- p.121 / Chapter 第三節 --- 分析單位：結構與能動者 --- p.124 / Chapter 一、 --- 結構與能動者 --- p.124 / Chapter 二、 --- 本研究的分析單位 --- p.128 / Chapter 第四節 --- 研究員的自我反省 --- p.130 / Chapter 一、 --- 對研究員個人社會特徵與經歷的反思 --- p.131 / Chapter 二、 --- 對研究員在學術場域中的位置的反思 --- p.135 / Chapter 三、 --- 對整個研究過程和研究方法的反思 --- p.137 / 本章小結 --- p.141 / Chapter 第四章 --- 研究框架與研究設計 --- p.142 / Chapter 第一節 --- 研究框架 --- p.142 / Chapter 第二節 --- 基本概念界定 --- p.146 / Chapter 一、 --- 社會醫療保險 --- p.146 / Chapter 二、 --- 弱勢老年人 --- p.148 / Chapter 三、 --- 醫療服務使用 --- p.149 / Chapter 四、 --- 健康水平 --- p.150 / Chapter 五、 --- 健康公平 --- p.151 / Chapter 第三節 --- 量化研究設計 --- p.153 / Chapter 一、 --- 研究假設 --- p.153 / Chapter 二、 --- 抽樣方法、問卷調查與二手數據分析 --- p.157 / Chapter 三、 --- 測量問題與分析模型 --- p.165 / Chapter 第四節 --- 質化研究設計 --- p.171 / Chapter 一、 --- 研究假設 --- p.171 / Chapter 二、 --- 樣本選擇與獲得進入 --- p.173 / Chapter 三、 --- 資料收集策略與分析方法 --- p.183 / Chapter 第五節 --- 研究的質素 --- p.190 / Chapter 一、 --- 量化與質化研究方法各自的信效度 --- p.190 / Chapter 二、 --- 混合研究方法的信效度：三角互證法 --- p.192 / 本章小結 --- p.197 / Chapter 第三部份 --- 研究發現 --- p.198 / Chapter 第五章 --- 量化研究發現 --- p.199 / Chapter 第一節 --- 改革前後被訪老人社會特徵的變化 --- p.199 / Chapter 一、 --- 基本特徵 --- p.200 / Chapter 二、 --- 社會經濟地位 --- p.204 / Chapter 三、 --- 社會支持網絡 --- p.208 / Chapter 第二節 --- 被訪老年人的健康水平與醫療服務使用情況 --- p.210 / Chapter 一、 --- 健康水平 --- p.210 / Chapter 二、 --- 醫療服務可及性及使用 --- p.220 / Chapter 第三節 --- 各保險項目參保老年人的健康不平等 --- p.227 / Chapter 一、 --- 各保險項目參保老年人的基本特徵 --- p.228 / Chapter 二、 --- 醫療保險類型與老年人的醫療服務使用 --- p.230 / Chapter 三、 --- 醫療保險類型與老年人的健康水平 --- p.233 / Chapter 第四節 --- 多元線性回歸分析：對健康水平的預測 --- p.236 / Chapter 一、 --- 建立多元線性回歸模型 --- p.239 / Chapter 二、 --- 多元線性回歸分析的結果 --- p.242 / 本章小結 --- p.248 / Chapter 第六章 --- 質化研究發現 --- p.250 / Chapter 第一節 --- 政策制定者：對形式公平與個人責任的強調 --- p.250 / Chapter 第二節 --- 基層醫生：因醫患矛盾和「付出-回報失衡」而產生的弱勢感 --- p.255 / Chapter 第三節 --- 弱勢老人：建立在「比較」基礎上的不公平感 --- p.259 / Chapter 一、 --- 農村老人與城鎮老人比較：社會福利不公平與弱勢地位的惡化 --- p.261 / Chapter 二、 --- 普通老人與離退休干部比較：身份地位差別引發的醫療服務不公平 --- p.264 / Chapter 三、 --- 只享受醫療保險的老人與低保對象比較：究竟誰更加弱勢？ --- p.266 / 本章小結：基於弱者優先的底線公平 --- p.271 / Chapter 第七章 --- 混合研究發現：醫療保險改革如何影響弱勢老人的健康公平 --- p.274 / Chapter 第一節 --- 浙江省社會醫療保障的改革實踐：機會公平 --- p.275 / Chapter 第二節 --- 路徑分析：醫療服務使用與健康水平的關係 --- p.279 / Chapter 一、 --- 醫療服務使用與健康水平的相關分析 --- p.280 / Chapter 二、 --- 路徑模型的建立、修正及結果 --- p.282 / Chapter 三、 --- 戶口-醫療服務使用-健康水平（最終的路徑模型） --- p.294 / Chapter 第三節 --- 交互作用分析：醫療保險的調節作用 --- p.299 / Chapter 一、 --- 「城鎮職工基本醫療保險」作為moderator --- p.299 / Chapter 二、 --- 「新型農村合作醫療」作為moderator --- p.302 / Chapter 第四節 --- 醫療保障制度改革中的過程公平與結果公平 --- p.306 / Chapter 一、 --- 過程公平：部門利益爭奪中「看病貴」問題喜憂參半的改革 --- p.306 / Chapter 二、 --- 結果公平：弱勢老人未被滿足的需要與不足夠的保障 --- p.310 / 本章小結 --- p.316 / Chapter 第四部份 --- 討論與結論 --- p.318 / Chapter 第八章 --- 討論 --- p.319 / Chapter 第一節 --- 「公平性」理論的反思與重構 --- p.319 / Chapter 一、 --- 反思醫療福利改革的理論基礎：對社會公義理論的發展 --- p.320 / Chapter 二、 --- 分析「底層健康公平」的理論機制：階層化身份地位差別的形成與變遷 --- p.325 / Chapter 第二節 --- 傳統微觀影響因素的再認識 --- p.332 / Chapter 一、 --- 健康水平：疾病風險變化與健康水平測量的發展 --- p.332 / Chapter 二、 --- 社會經濟地位：從關注收入轉向關注疾病的經濟負擔 --- p.334 / Chapter 三、 --- 戶籍狀況：影響的消除還是持續？ --- p.336 / Chapter 第三節 --- 結果公平的全民醫療保險制度改革 --- p.339 / Chapter 一、 --- 全民醫療保險的角色反思：從機會公平到結果公平 --- p.339 / Chapter 二、 --- 從醫療服務使用到健康結果：全民醫療保險的新路徑倡導 --- p.341 / Chapter 三、 --- 醫療保險改革與醫藥體制改革的互動 --- p.344 / Chapter 第四節 --- 以社區為中心的綜合健康服務與長期照顧體系初探 --- p.349 / Chapter 一、 --- 社會支持網絡：擴展的視角 --- p.349 / Chapter 二、 --- 美國社區健康中心與長期照顧服務的啟示 --- p.351 / Chapter 三、 --- 對中國建立社區綜合健康服務與長期照顧體系的啟示 --- p.355 / 本章小結 --- p.357 / Chapter 第九章 --- 結論與建議 --- p.359 / Chapter 第一節 --- 結論 --- p.359 / Chapter 一、 --- 「底層健康公平」價值選擇的特殊意涵 --- p.360 / Chapter 二、 --- 混合研究發現「過程公平」與「主觀公平」的重要性 --- p.362 / Chapter 三、 --- 健康公平社會影響因素的新變化與新發現 --- p.363 / Chapter 四、 --- 改革中醫療保險對健康公平的調節作用 --- p.364 / Chapter 第二節 --- 建議 --- p.367 / Chapter 一、 --- 醫療保障政策建議 --- p.367 / Chapter 二、 --- 醫療與醫藥政策的配合：推動「過程公平」的需要 --- p.371 / Chapter 三、 --- 社會醫療保險改革對醫療服務發展的啟示 --- p.373 / Chapter 第三節 --- 貢獻、局限與研究展望 --- p.375 / Chapter 一、 --- 本研究的貢獻 --- p.375 / Chapter 二、 --- 本研究的局限 --- p.379 / Chapter 三、 --- 未來的研究方向 --- p.381 / 結束語 --- p.384 / 參考文獻 --- p.386 / 附錄 --- p.423 / Chapter 附錄1. --- 調查問卷 --- p.423 / Chapter 附錄2. --- 數據使用協議 --- p.441 / Chapter 附錄3. --- 知情同意書 --- p.442 / Chapter 附錄4. --- 訪談提綱 --- p.443

Á l’instar des autres pays d’Afrique subsaharienne, le Burkina Faso rencontre encore d’énormes difficultés pour assurer des soins de santé de qualité, et financièrement accessibles à leurs populations. Insuffisance des structures sanitaires, coût élevé des prestations sanitaires, personnel démotivé, corruption, mauvaise qualité des soins sont autant de maux qui fragilisent le dispositif sanitaire. Abandonnées à elles mêmes, les populations utilisent plusieurs itinéraires thérapeutiques pour résoudre leur problème de santé. Guérisseurs traditionnels, consultation de devins, consommation des médicaments de rue, fréquentation simultanée des structures sanitaires et « médecins traditionnels », sont autant de ressources mises à contribution par les individus, pour vaincre la maladie. Les croyances des populations à ces pratiques restent très fortes et répondent à une certaine rationalité. Non seulement, elles ont été léguées de générations en générations mais elles ont fait leurs preuves et continuent même d’être une référence. L’étude révèle que les populations adhèrent de plus en plus aux systèmes de mutualisation des risques sanitaires. Les individus se détachent des contraintes des systèmes d’organisation classiques, en s’orientant vers des choix thérapeutiques beaucoup plus autonomes et individualisés.L’étude montre également les dysfonctionnements, mais aussi les espoirs que suscitent l’implantation des mutuelles de santé, notamment la mutuelle de santé Laafi baoré du secteur informel, la mutuelle rurale de Poa. Ces mutuelles connaissent quasiment les mêmes difficultés : contraintes culturelles, pluralité des itinéraires thérapeutiques, pauvreté des populations, irrégularité des revenus, retard de paiement des cotisations, faible engagement de l’État. Par ailleurs, l’analyse des caractéristiques socio culturelles des populations, nous enseigne la nécessité de prendre en compte, et prioritairement les valeurs sociales intériorisées par les populations concernées dans la mise en place des projets d’assurance maladie. / Like of the other fellow-countryman of sub-Saharan Africa, the meeting Burkina still of enormous difficulties to settle oneself firmly of the cares of health of quality, and financially accessible to their populations. Insufficiency of the structure medical, high cost of the medical, personal furnishings, corruption, and bad quality of the cares is as much ills that weaken the medical device. Abandoned to they same, the populations use several therapeutic itineraries to solve their problem of health. Traditional healers, consultation of diviners, consummation of the medicines of street, simultaneous frequenting of the structure medical and « traditional doctors » are as much revitalize put to tax by the individuals, to defeat the illness. The beliefs of the populations to these practices remain very strong and answer to a certain rationality. Not only, they have been bequeathed of generations in generations, but they did their proofs and continue same to be a reference. To that, the study reveals that the populations adhere more and more to the systems of mutualisation of the medical risks. The individuals detaches to him of the constraints of the systems of academic organization in orienting towards of the much more autonomous therapeutic choice and individualized. Also, the study shows the dysfunctions, but also the hopes that give rise to the planting of the mutual thing of health, notably the mutual thing of Laafi baoré health of the casual sector, the mutual rural thing of Poa. These mutual know almost the same difficulties: cultural constraints, plurality of the therapeutic itineraries, poverty of the populations, irregularity of the incomes, delay of payment of the quotas, feeble pawning of the state. By another way, the analysis of the features socio cultural of the populations, we teaches the necessity taking in account, and as a priority the social values interiorized by the concerned populations in the setting up of the plans of health insurance.