Even in the United States, vertical

Even in the United States, vertical integration under health maintenance organizations
(HMOs) is being eclipsed by virtual integration between the provider network HMOs,other provider groups, and a globalized insurance industry. Vertical integration between
production and distribution units is now being viewed as a coordination mechanism of last
resort, and is used mainly when contractual alternatives are not available (60).
Efforts at virtual integration face three common problems, related to decentralization,
separating purchasers from providers, and user charges. In many countries, there has recently
been an increased enthusiasm for decentralization as a means of attaining a wide
variety of policy and political goals in health as in other areas. The explicit objective of
decentralization is often to improve responsiveness and incentive structures by transferring
ownership, responsibility and accountability to lower levels of the public sector. This is
usually done through a shift in ownership from the central government to local levels of the
public sector – states or provinces, regions, districts, local communities, and individual publicly
owned facilities.
A common difficulty with such reforms has been that the internal structural problems of
the hospitals, clinics and public health facilities do not disappear during the transfer. In
Uganda, decentralization did not close the financing gap experienced by many health facilities.
In Sri Lanka, decentralization exposed weak management capacity but failed to
address it. In Ghana, the unfunded social obligations were passed on to lower levels of
government which did not have the financial capacity to absorb this responsibility because
the proposed social insurance reforms had stalled. In many cases, central governments
reassert control in a heavy-handed fashion when local governments deal with politically
sensitive issues in a way that does not accord with the views of the national government on
how such issues should be treated.
Where there is a split between purchasers and providers, similar tensions often arise. In
Hungary and also in New Zealand there has been conflict between purchasing agencies
situated in different branches of the government and still responsible for stewardship (such
as ministries of health and finance) and the owners of the contracted providers (such as
municipalities and local governments). In Hungary, constitutional powers were given to a
self-governing National Health Insurance Fund that was controlled by the labour unions
during the early 1990s. For about eight years, until the abolition of this arrangement in
1998, there was an open conflict between the Ministry of Finance and the Health Insurance
Fund over fiscal policy and expenditure control. Providers were often not paid on time.
Finally, the introduction of user fees creates tensions between policy-based and prepaid
purchasing and market-driven purchases of services by individual consumers. This has
been especially true in many of the central Asian republics and in countries affected by the
east Asia crisis, where the revenues channelled through policy-based purchasing have experienced
a dramatic drop in recent years. This can undermine national policies on priority
setting and cost containment, and as discussed in Chapter 2, it makes financing much less
fair. The issue of how to organize purchasing as an integral part of the financing function is
treated at more length in Chapter 5.
In order to attain the goals of good health, responsiveness and fair financial contribution,
health systems need to determine some priorities and to find mechanisms that lead
providers to implement them. This is not an easy task, because of two sources of complexity.
Priorities should reflect a variety of criteria that are sometimes in conflict, and that
requires a great deal of information that most health systems simply do not now have
available. And to make priorities effective requires a mixture of rationing mechanisms, organizational
structures, institutional arrangements and incentives for providers that must
above all be consistent with one another and with the goals of the system.

結果 (繁體中文) 1:

即使在美國，健康維護組織下的縱向一體化(Hmo) 黯然失色虛擬集成供應商網路保健組織、 其他供應商群體和一個全球化的保險行業之間。之間的縱向一體化生產及經銷單位現在是被看成是最後一個協調機制度假村，並主要用於對合同的替代品不是可用的 (60)。在虛擬一體化的努力面臨三個常見的問題，有關權力下放，分離供應商和使用者收費的買家。在許多國家，最近有已增加的熱情為權力下放作為一種手段的實現全各種政策和在其他領域的健康的政治目標。明確目的權力下放是經常通過轉移，提高回應能力和激勵結構擁有權、 責任和問責制的公共部門更低級別。這是通常通過完成擁有權轉移從中央到地方各級的公共部門 — — 國家或省份、 地區、 地區、 地方社區和個人公開擁有設施。這種改革共同困難一直是內部的結構問題在傳輸過程中不會消失的醫院、 診所和公共衛生設施。在烏干達，權力下放沒有關閉經歷的許多保健設施的資金缺口。在斯里蘭卡，權力下放暴露管理能力弱，但對失敗解決它。在加納，資金沒有著落的社會責任都轉嫁到較低級別的政府並沒有因為吸收這一責任的財政能力擬議的社會保險改革已經停止了。在許多情況下，中央政府地方政府在政治上處理時重申控制中一種嚴厲的方式敏感的問題，對不符合國家政府的意見的方式如何對待這種問題。哪裡有買家和供應商之間的分裂，類似的緊張經常出現。在匈牙利，也有在紐西蘭已經採購代理機構之間的衝突坐落在不同政府部門的和仍然負責管理 (例如，作為衛生部和財政部) 和業主的合同供應商 (如市政當局和地方政府)。在匈牙利，給予憲法權力受勞工工會的自治國家健康保險基金1990 年代初期。約八年，直到取消這項安排1998 年，有了財政部和健康保險之間的公開衝突在財政政策和支出控制基金。供應商常常不按時繳納。最後，實行使用者收費基於策略和預付之間製造緊張局面purchasing and market-driven purchases of services by individual consumers. This hasbeen especially true in many of the central Asian republics and in countries affected by theeast Asia crisis, where the revenues channelled through policy-based purchasing have experienceda dramatic drop in recent years. This can undermine national policies on prioritysetting and cost containment, and as discussed in Chapter 2, it makes financing much lessfair. The issue of how to organize purchasing as an integral part of the financing function istreated at more length in Chapter 5.In order to attain the goals of good health, responsiveness and fair financial contribution,health systems need to determine some priorities and to find mechanisms that leadproviders to implement them. This is not an easy task, because of two sources of complexity.Priorities should reflect a variety of criteria that are sometimes in conflict, and thatrequires a great deal of information that most health systems simply do not now haveavailable. And to make priorities effective requires a mixture of rationing mechanisms, organizationalstructures, institutional arrangements and incentives for providers that mustabove all be consistent with one another and with the goals of the system.

結果 (繁體中文) 2:

即使在美國，在健康維護組織垂直整合
（HMOs）的正黯然失色提供商網絡保健組織之間的虛擬整合，其他的供應商群體，以及全球化的保險業。之間的垂直整合
生產和經銷單位，現在被視為最後的協調機制
的度假勝地，主要用於當合同的替代品不可用（60）。
努力在虛擬一體化面臨三個共同的問題，涉及到權力下放，
從供應商分離買家和用戶收費。在許多國家，最近
一直是權力下放的積極性上升為達到寬的手段
各種政策和健康的政治目標，在其他地區。的明確目標
的權力下放往往是通過轉移來提高響應能力和激勵機制
的所有權，責任制和問責制，以公共部門的較低水平。這
通常是通過所有權的轉變，從中央到地方各級進行
公共部門-國家或省，區，縣，地方社區和個人公開
。所有的設施，
一個共同的困難這樣的改革一直是內部結構問題
的醫院，診所和公共衛生設施在傳輸過程中不會消失。在
烏干達，權力下放並沒有彌補資金的缺口所經歷的許多衛生設施。
在斯里蘭卡，權力下放暴露管理能力較弱，但未能
解決這一問題。在加納，資金沒有著落的社會責任被轉嫁到下級
政府，沒有足夠的經濟能力來吸收這種責任，因為
所提出的社會保險改革已經停滯。在許多情況下，中央政府
重申控制在一個笨拙的方式，當地方政府解決政治
在不與國家政府的意見給予了一種敏感問題
如何等問題應及時治療。
哪裡有電光火石間採購商和供應商，類似的緊張經常出現。在
匈牙利以及在新西蘭出現了採購機構之間的衝突
坐落在政府各部門仍負責管理工作（如
衛生和財政部），合同供應商的業主（如
市政當局和地方政府） 。在匈牙利，憲法權力被給了一個
自我管理的國民健康保險基金，是由工會控制
在90年代初。約8年，直到這種安排取消在
1998年，有財政部和醫療保險之間的公開衝突
過的財政政策和支出控制基金。供應商經常不能按時發放。
最後，引入用戶付費創建基於策略和預付費之間的緊張
採購和市場為導向的採購個人消費者的服務。這
是尤其如此，在許多中亞共和國，並在受影響的國家的
東亞危機的影響，其中，通過基於策略的採購渠道的收入已經經歷了
近幾年急劇下降。這可能會破壞優先國家政策
制定和成本控制，並在第2章所討論的，它使資金少得多
公平的。如何組織採購的融資功能的一個組成部分的問題
處理在多個長度在第5章
為了獲得良好的健康，快速響應和公允的財務貢獻的目標，
衛生系統需要確定一些優先事項，並找到導致機制
提供商實施。這不是一件容易的事，因為複雜性有兩個來源。
重點應體現的各種各樣的有時是衝突的標準，這
需要大量的信息，大多數衛生系統根本就沒有現在
可用。而為了讓有效的優先需要配給機制，組織的混合
結構，制度安排和激勵供應商必須
首先與彼此之間以及與該系統的目標是一致的。

結果 (繁體中文) 3:

即使在美國，健康維護組織（HMO）
下垂直整合是由供應商網絡之間的虛擬集成HMO黯然失色，其他組織提供服務，和全球保險業。生產和分配組織之間的垂直整合，現在被認為是一個協調機制的最後一個，主要是在契约的替代品不可用（60），在虛擬綜合的努力，面對三個共同的問題，涉及到權力下放，從供應商，和用戶的分離。在許多國家，最近有一個新增的積極性作為一種手段，實現一個廣泛的權力下放衛生領域的政策和政治目標的多樣性。權力下放的明確目標，往往是通過轉移所有權，責任和問責機制，以降低公共部門的水准，以提高響應性和激勵結構。這通常是通過從中央政府到地方各級的所有權轉移來完成的公共部門，國家或地區，地區，地方社區，個人的公共設施，如一個共同的困難，這樣的改革已經被的內部結構問題的的醫院，診所和公共衛生設施不消失，在轉移過程中。在烏干達，權力下放並沒有關閉許多衛生設施所經歷的資金缺口。