誰應為醫療保健買單？——中國城鎮衛生籌資責任主體歷史演進的儒家反思

Who Should Pay for Health Care? Confucian Reflections on the Historical Evolution of Financing Responsibilities for Health Care in Urban China

Abstract

LANGUAGE NOTE | Document text in Chinese; abstract also in English.

一個道德上公正的醫療保健制度，不僅應該保障人人都可以均等地獲得基本的衛生保健服務，還應該是財務上可持續的。醫療保健制度籌資責任主體一般包括政府、個人、家庭等，各籌資主體責任大小對實現一國或一地區衛生資源的有效配置、為當地居民提供公平而又有效的醫療衛生服務至關重要。

本文將建國以來中國城鎮地區醫療保健制度的發展演進劃分為四個階段，分別是計劃經濟時期、經濟制度轉軌時期、市場經濟初期、全民基本醫療保險時期，基於儒家生命倫理原則，對中國（內地）城鎮地區衛生籌資責任主體進行回顧、反思，分析認為中國衛生籌資責任主體發展經歷了「政府大包大攬、個人及家屬免費享受」——「政府財政逐漸退出、個人及家庭負擔加重」——「 政府責任回歸、個人負擔有所下降」——「政府、市場、個人責任逐漸趨於均衡」這一過程。基於儒家衛生正義觀，本文認為「仁政」不是絕對平均主義，也非個人全權負責；「家庭本位」的傳統文化在中國一直活躍至今，制度安排亟需家庭責任的回歸。在儒家看來，一個道德上合理的衛生籌資責任，應該是個人、家庭和政府的平衡與和諧。

A morally justifiable health care system should not only ensure that everyone has equal access to basic health care services, but also be financially sustainable. It is normally supposed that governments, individuals and families take joint responsibility for health care in a certain country or region. Their levels of financial responsibility are a significant factor in the effective allocation of healthcare resources and fair delivery of health care services.

This paper divides the historical evolution of health care financing responsibilities in urban China since 1949 into four periods: a planned economy period, an economic system transition period, an initial period of market economy and a universal health coverage period. Based on Confucian ethical principles, the author reflects on financing responsibilities in urban China. She determines that the financing responsibilities of different periods have changed from government- to individual-dominant, finally achieving a balance between government, the market and the individual. The author argues that from a moral standpoint, according to Confucian ethical appeals on health justice, a benevolent government should practice neither the doctrine of absolute equalization nor the principle of individual liberalism. As the idea that the family comprises the primary community is still active in contemporary China, family responsibility should be emphasized along with health care financing policy. According to Confucianism, a morally just health care financing responsibility requires a proper balance and harmony between individuals, families and governments.

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