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醫(yī)學(xué)

本文英文部分選自經(jīng)濟(jì)學(xué)人Leaders版塊

Universal health care, worldwide, is within reach

全民醫(yī)療保險(xiǎn)觸手可及

The case for it is a powerful one—including in poor countries

這在貧窮國家亦有極強(qiáng)可行性

BY MANY measures the world has never been in better health. Since 2000 the number of children who die before they are five has fallen by almost half, to 5.6m. Life expectancy has reached 71, a gain of five years. More children than ever are vaccinated. Malaria, TB and HIV/AIDS are in retreat.

從許多方面看，世界從未像現(xiàn)在這樣健康過。自2000年以來，五歲前兒童夭折數(shù)量下降了一半，至560萬。人類預(yù)期壽命提高5年，達(dá)到71歲。接種疫苗的兒童比以往任何時(shí)期都多，瘧疾、結(jié)核病和艾滋病正在消退。

Yet the gap between this progress and the still greater potential that medicine offers has perhaps never been wider. At least half the world is without access to what the World Health Organisation deems essential, including antenatal care, insecticide-treated bednets, screening for cervical cancer and vaccinations against diphtheria, tetanus and whooping cough. Safe, basic surgery is out of reach for 5bn people.

然而，相較于醫(yī)學(xué)的更大潛力，眼下這些進(jìn)步也許仍差之千里。世界上至少一半的國家無法獲得世界衛(wèi)生組織認(rèn)定的最基礎(chǔ)的醫(yī)療服務(wù)，包括產(chǎn)前保健、經(jīng)殺蟲劑處理的蚊帳、宮頸癌篩查以及預(yù)防白喉、破傷風(fēng)、百日咳的疫苗接種。有50億人得不到安全的基本外科手術(shù)治療。

Those who can get to see a doctor often pay a crippling price. More than 800m people spend over 10% of their annual household income on medical expenses; nearly 180m spend over 25%. The quality of what they get in return is often woeful. In studies of consultations in rural Indian and Chinese clinics, just 12-26% of patients received a correct diagnosis.

那些能去看醫(yī)生的人往往花錢不菲。超過8億人每年家庭收入的10%用于醫(yī)療，更有將近1.8億家庭超過25%，而他們得到的服務(wù)卻是槽糕的。在對印度和中國農(nóng)村診所進(jìn)行的咨詢研究中，只有12%-26%的患者得到了正確的診斷。

That is a terrible waste. As this week’s special report shows, the goal of universal basic health care is sensible, affordable and practical, even in poor countries. Without it, the potential of modern medicine will be squandered.

這是一種嚴(yán)重的浪費(fèi)。正如這周特別報(bào)導(dǎo)所表明的，實(shí)現(xiàn)全民基本醫(yī)療保健這一目標(biāo)合理、可負(fù)擔(dān)，也實(shí)際，即使在貧窮國家也是如此。沒有全民基本醫(yī)療，現(xiàn)代醫(yī)學(xué)的潛力會(huì)被浪費(fèi)。

How the other half dies

另一半人是如何死去的

Universal basic health care is sensible in the way that, say, universal basic education is sensible—because it yields benefits to society as well as to individuals. In some quarters the very idea leads to a dangerous elevation of the blood pressure, because it suggests paternalism, coercion or worse. There is no hiding that public health-insurance schemes require the rich to subsidise the poor, the young to subsidise the old and the healthy to underwrite the sick. And universal schemes must have a way of forcing people to pay, through taxes, say, or by mandating that they buy insurance.

如果說，全民基礎(chǔ)教育是合理的，那依據(jù)同樣的道理，全民基本醫(yī)療也是合理的——因?yàn)樗鼘€(gè)人和社會(huì)都有好處。然而這個(gè)想法對于某些人群來說，會(huì)讓他們血壓飆升，因?yàn)檫@意味著家長式管理、強(qiáng)迫或更糟的事。直言不諱，公共醫(yī)療保險(xiǎn)計(jì)劃需要富人補(bǔ)貼窮人，年輕人補(bǔ)貼老人，健康的人補(bǔ)貼病人。全民醫(yī)療計(jì)劃必須采取辦法強(qiáng)迫人們繳費(fèi)，通過收稅，或強(qiáng)制他們買保險(xiǎn)。

But there is a principled, liberal case for universal health care. Good health is something everyone can reasonably be assumed to want in order to realise their full individual potential. Universal care is a way of providing it that is pro-growth. The costs of inaccessible, expensive and abject treatment are enormous. The sick struggle to get an education or to be productive at work. Land cannot be developed if it is full of disease-carrying parasites. According to several studies, confidence about health makes people more likely to set up their own businesses.

但是，全民醫(yī)療保險(xiǎn)也具有其原則性和自由度。我們可以合理地認(rèn)為每個(gè)人都想得到一副好身體，從而全面發(fā)揮自己的潛在能力。而全民醫(yī)療保險(xiǎn)便是能夠賦予大家好身體的其中一種方法，并且還能夠促進(jìn)經(jīng)濟(jì)的增長。看病難、看病貴、治療差所造成的損失是巨大的。病患為了能夠上學(xué)、正常工作而苦苦掙扎。像是一塊土地如果長滿寄生蟲，而且這些寄生蟲還能夠傳播疾病，那么這塊土地將無法得以開發(fā)。多項(xiàng)研究表明，對健康有自信的人更愿意創(chuàng)業(yè)。

Universal basic health care is also affordable. A country need not wait to be rich before it can have comprehensive, if rudimentary, treatment. Health care is a labour-intensive industry, and community health workers, paid relatively little compared with doctors and nurses, can make a big difference in poor countries. There is also already a lot of spending on health in poor countries, but it is often inefficient. In India and Nigeria, for example, more than 60% of health spending is through out-of-pocket payments. More services could be provided if that money—and the risk of falling ill—were pooled.

全民基本醫(yī)療保險(xiǎn)也并非難以負(fù)擔(dān)。一個(gè)國家無需待到富庶之時(shí)才能實(shí)現(xiàn)全面且基本的衛(wèi)生治療。衛(wèi)生保健產(chǎn)業(yè)是勞動(dòng)密集型產(chǎn)業(yè)。跟醫(yī)生和護(hù)士相比，向轄區(qū)衛(wèi)生工作者所支付的酬勞也相對較低。因此，在貧窮國家中，轄區(qū)衛(wèi)生工作者的意義重大。貧窮國家的衛(wèi)生花費(fèi)已經(jīng)相當(dāng)大，但其所帶來的效益卻常常不如人意。在印度以及尼日利亞，百分之六十以上的衛(wèi)生費(fèi)用都是患者直接自付的。如果這些錢可以籌集在一起，并且患病風(fēng)險(xiǎn)可以集中管控，那么這將能夠?yàn)榇蠹姨峁└喾?wù)。

The evidence for the feasibility of universal health care goes beyond theories jotted on the back of prescription pads. It is supported by several pioneering examples. Chile and Costa Rica spend about an eighth of what America does per person on health and have similar life expectancies. Thailand spends $220 per person a year on health, and yet has outcomes nearly as good as in the OECD. Its rate of deaths related to pregnancy, for example, is just over half that of African-American mothers. Rwanda has introduced ultrabasic health insurance for more than 90% of its people; infant mortality has fallen from 120 per 1,000 live births in 2000 to under 30 last year.

全民醫(yī)療保險(xiǎn)可行性的證明并非是紙上談兵，開拓性的實(shí)例已有證實(shí)。智利和哥斯達(dá)黎加只花費(fèi)了美國個(gè)人健康保險(xiǎn)費(fèi)用的1/8，但有著相似的預(yù)期壽命。泰國每人每年在醫(yī)保上花費(fèi)220美元，但卻取得了和經(jīng)合組織國家一樣好的效果，舉個(gè)例子，與妊娠有關(guān)的死亡率，僅僅只有非裔美國媽媽的一半多一點(diǎn)。盧萬達(dá)為其90%以上的人民引入了非?；A(chǔ)的醫(yī)療保險(xiǎn)，嬰兒死亡率從2000年的千分之一百二十降低至去年的千分之三十不到。

And universal health care is practical. It is a way to prevent free-riders from passing on the costs of not being covered to others, for example by clogging up emergency rooms or by spreading contagious diseases. It does not have to mean big government. Private insurers and providers can still play an important role.

全民醫(yī)療保險(xiǎn)是實(shí)用的，它能避免“占便宜”的不參保人群把成本轉(zhuǎn)嫁給參保的人，比如占用急診室或者擴(kuò)散傳染病。而這也并不意味著全靠政府大包大攬，私有保險(xiǎn)公司和供應(yīng)商也仍將發(fā)揮著重要的作用。

Indeed such a practical approach is just what the low-cost revolution needs. Take, for instance, the design of health-insurance schemes. Many countries start by making a small group of people eligible for a large number of benefits, in the expectation that other groups will be added later. (Civil servants are, mysteriously, common beneficiaries.) This is not only unfair and inefficient, but also risks creating a constituency opposed to extending insurance to others. The better option is to cover as many people as possible, even if the services available are sparse, as under Mexico‘s Seguro Popular scheme.

實(shí)際上，這種務(wù)實(shí)的做法正是低成本改革所需要的。例如，醫(yī)療保險(xiǎn)計(jì)劃的設(shè)計(jì)。許多國家的開始是讓一小部分人有資格獲得大量的福利，期望以后會(huì)增加其他群體。（神奇的是，公務(wù)員總是受益者。）這不僅是不公平和低效的，而且也有可能造成反對向他人提供保險(xiǎn)保障的選民。更好的選擇是盡可能多地覆蓋盡可能多的人，即便現(xiàn)有的服務(wù)很少，就像墨西哥的“大眾醫(yī)療保險(xiǎn)”那樣。

Small amounts of spending can go a long way. Research led by Dean Jamison, a health economist, has identified over 200 effective interventions, including immunisations and neglected procedures such as basic surgery. In total, these would cost poor countries about an extra $1 per week per person and cut the number of premature deaths there by more than a quarter. Around half that funding would go to primary health centres, not city hospitals, which today receive more than their fair share of the money.

少量的支出任重道遠(yuǎn)。由健康經(jīng)濟(jì)學(xué)家迪恩賈米森領(lǐng)導(dǎo)的研究已經(jīng)確定了超過200種有效的干預(yù)措施，包括免疫接種和基本手術(shù)等被忽視的手段?？偟膩碚f，這些措施將使貧窮國家每人每周多出1美元，但這能將過早死亡人數(shù)減少逾四分之一。大約一半的資金將用于初級衛(wèi)生中心，而不是城市醫(yī)院，這些醫(yī)院如今獲得的資金超過了它們應(yīng)得的份額。

The health of nations

世界各國的醫(yī)療

Consider, too, the $37bn spent each year on health aid. Since 2000, this has helped save millions from infectious diseases. But international health organisations can distort domestic institutions, for example by setting up parallel programmes or by diverting health workers into pet projects. A better approach, seen in Rwanda, is when programmes targeting a particular disease bring broader benefits. One example is the way that the Global Fund to Fight AIDS, Tuberculosis and Malaria finances community health workers who treat patients with HIV but also those with other diseases.

我們看一下每年花在世界醫(yī)療救助上的370億美元。自2000年來，這些投資挽救了數(shù)百萬的傳染病病人。但是，各種世界衛(wèi)生組織可能會(huì)歪曲各國國內(nèi)衛(wèi)生組織的工作方向，比如要求國內(nèi)衛(wèi)生組織設(shè)立類似平行項(xiàng)目或者將衛(wèi)生工作者分配到寵物項(xiàng)目。盧旺達(dá)找到了一個(gè)好方法，就是某一疾病的專項(xiàng)基金并不局限于單一項(xiàng)目。。例如，針對艾滋病、肺結(jié)核和瘧疾的全球衛(wèi)生基金，補(bǔ)助給轄區(qū)衛(wèi)生工作者，讓他們既能治療艾滋病人，也能幫助其他病患。

Europeans have long wondered why the United States shuns the efficiencies and health gains from universal care, but its potential in developing countries is less understood. So long as half the world goes without essential treatment, the fruits of centuries of medical science will be wasted. Universal basic health care can help realise its promise.

歐洲人一直搞不懂，為何美國不接受全球衛(wèi)生項(xiàng)目所帶來的效率和健康收益，卻少有人了解這一機(jī)制在發(fā)展中國家的巨大潛力。為了不讓醫(yī)學(xué)進(jìn)步的碩果成為一紙空談，就得讓全世界半數(shù)的人群得到必要保障。全民基本醫(yī)療保險(xiǎn)將讓這個(gè)目標(biāo)成為現(xiàn)實(shí)。

翻譯組：

Cece，女，消防工作者，CATTI三筆

Neil,  男，外貿(mào)民工，經(jīng)濟(jì)學(xué)人鐵粉

Cyrus，男， 口譯民工，經(jīng)濟(jì)學(xué)人愛好者

Alieen，女，大四數(shù)學(xué)狗，經(jīng)濟(jì)學(xué)人愛好者

Doris，女，法律學(xué)習(xí)者，經(jīng)濟(jì)學(xué)人愛好者

校核組：

Samantha，女，外企低管，鄧倫未婚妻 

Eva , 女，經(jīng)貿(mào)翻譯學(xué)生，經(jīng)濟(jì)學(xué)人愛好者