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標題: | 窮人銀行開醫院的角色衝突:孟加拉經驗探索 When creditor and health provider collide: exploring microfinance-based hospitals in Bangladesh |
作者: | Yu-hwei Tseng 曾育慧 |
指導教授: | 鄭雅文(Yawen Cheng) |
關鍵字: | 微額貸款,微貸機構,孟加拉,醫院醫療服務利用,健康不平等,除貧, microcredit,microfinance institution,Bangladesh,hospital care utilization,health inequality,poverty alleviation, |
出版年 : | 2015 |
學位: | 博士 |
摘要: | 前言:微額貸款機構(微貸機構)提供的醫療服務宣稱照顧窮人,但受惠者是否包含最貧窮的人群,目前尚屬未知。本研究以孟加拉為田野,調查微貸機構設立的醫院(微貸醫院)中病人社經處境與醫院運作情形,並與公立醫院做比較,藉此了解微貸機構經營醫院的策略是否與其宣稱的友善窮人宗旨一致。本研究包含兩部份。第一部份針對病人,在門診向候診病人進行問卷調查,蒐集影響醫院醫療服務利用的前傾、使能與需求三類決定因子;第二部份針對醫院,採用質性研究方法,依據健康體系重要面向,包括服務提供、人力、財務等,透過深入訪談與參與式觀察的方式做資料蒐集。研究者將分析來自所有利害相關人,從照護提供者、使用者、決策者到微貸工作人員的資料,呈現微貸機構參與健康部門的現況並討論政策意涵。
方法:本研究為橫斷研究。第一部份由訪員在醫院採便利取樣,向女性門診病人進行問卷調查,有效樣本共347份,分別來自微貸醫院177名與公立醫院170名。蒐集的自變項資料包括年齡、教育、婚姻狀況、家庭人口數、是否參與微貸以及參與時間、家戶所得、自評健康與自覺需求。依變項為是否使用微貸醫院。統計分析使用卡方檢定與廣義估計方程式(Generalized Estimating Equations)。質性研究的訪談對象有微貸機構高階經理人、病人、公立醫院與微貸醫院的管理階層與照護提供者、中央與地方衛生官員與學者共27名。為確保兩種類型的利益相關者均能納入,受訪者由立意取樣方式產生。其它資源來源亦包括研究者的參與式觀察、田野筆記和微貸機構出版品。質性資料的分析採用架構分析法(framework analysis),依據服務提供、資源、提供者的行為模式、人力、利用情況、可近性等關鍵主題做資料的歸納與分析。最後,研究者整合可彼此呼應的質量性結果,提出結論。 結果:與公立醫院相比,微貸醫院的利用與下列因素有顯著相關,包括加入微貸機構會員達五年以上(OR=2.9, p<.01)、中等貧窮家戶(OR=4.09, p<.001)、非貧窮家戶(OR=7.34, p<.01),以及預防性健康服務的需求(OR=3.4, p<.01)。微貸會員使用微貸醫院的機率較高,但此效果僅限於來自非貧窮與中等貧窮家戶的病人。若同時從經濟地位與是否為微貸客戶兩個面向觀之,不貧窮的微貸客戶、中等貧窮的微貸客戶、不貧窮的非微貸客戶使用微貸醫院的機率,分別是最窮的非微貸客戶的7.46、6.91與4.48倍。然而,雖然統計上不顯著,但最貧窮的微貸客戶與微貸醫院的利用關係呈現負向。此外,病人在微貸醫院使用的項目多半為預防性服務,醫療費用卻顯著較高。 質性調查發現公立醫院提供全面性且價格低廉的照護,但包括人力在內的現有軟硬體依然不足以因應。在醫療費用方面,微貸醫院收費僅比私人診所稍低,卻比公立醫院高出數倍至百倍不等;在人力方面,微貸醫院採用彈性雇用策略以節省人事成本;在財源方面,微貸醫院同時透過定價和選擇輕症病人來提高收入,而為增加病人量,微貸機構亦支付佣金鼓勵社區服務人員來招攬病人或推銷套裝服務。關於微貸機構的社會責任,以及公部門與微貸部門的合作內涵,前者期待微貸做為非政府組織,應投入基層的衛生保健,然後後者卻主張不同社經階層病人的分流。對於微貸醫院的商業化走向,主管機關的意見出現明顯的分歧。 結論:與公立醫院相比,微貸醫院存在明顯的使用不平等,顯然與其宣稱的宗旨不符。政府從一開始扶持微貸機構,之後對於微貸機構涉入醫院經營亦採取自由放任的態度似乎助長此風。本文作者認為,在缺乏立場明確的政策引導和規範之下,以微貸做為平台來提供公共服務或期待微貸結合醫療能夠強化健康體系,可能無法達到除貧或提昇人群健康福址的目標。建議微貸機構的健康方案與微貸業務分開,並調整健康計畫的方向,以提供普及且公平的基層保健服務為主軸。其次,建議政府的微貸與健康主管機關針對微貸機構經營之醫療院所加以定位,納入監督與規範。本研究提供的實證資料,對於政府部門、微貸機構與發展援助組織具有政策參考價值。 Introduction: Health programs implemented by microfinance institutions (MFIs) aim to benefit the poor, but whether these services reach the poorest remains uncertain. This study intended to investigate the patient profiles and policies in the hospitals operated by microfinance institutions (MFI hospitals) in Bangladesh and make a comparison with public hospitals to determine if such initiatives were consistent with their pro-poor mandate. This research came in two parts. The first part paid attention to patients. A survey was conducted to examine patients’ hospital utilization by predisposing, enabling and need determinants. The second part focused on hospitals. It took advantage of qualitative approach to probe into the service delivery, manpower, financing and other aspects of the health care system through in-depth interviews and observation. Drawing on the evidence derived from stakeholders such as providers, users, policy makers and practitioners, implications of MFI hospital-based programs were discussed. Methods: In this cross-sectional study, the author used the convenience sampling method to administer an interviewer-assisted questionnaire survey among 347 female outpatients, with 177 in MFI hospitals and 170 in public hospitals. Independent variables were patient characteristics categorized into predisposing factors (age, education, marital status, family size), enabling factors (microcredit membership, household income) and need factors (self-rated health, perceived needs for care). The statistical method of Generalized Estimating Equations (GEE) was employed to evaluate how these factors contributed to MFI hospital use. In the qualitative approach, details on the provision of hospital care in the public and MFI sectors were collected among 27 stakeholders, including microcredit practitioners and borrowers, MFI hospital managers, MFI regulatory bodies, care providers, academics, and health officials at central and local levels. Respondents were recruited by using purposive sampling to ensure inclusion of critical cases from two types of care. Other data sources included researchers’ observation, field notes and publications provided by interviewees. Data were analyzed using framework analysis which established steps to deal with data according to key issues and themes. Key themes included service delivery, resources, provider behavior, manpower, utilization, affordability and implications. Finally, results from the interviews were combined with findings from the quantitative study before drawing conclusions. Results: Use of MFI hospitals was significantly associated with microcredit membership over 5 years (OR=2.9, p<.01), moderately poor household (OR=4.09, p<.001), non-poor household (OR=7.34, p<.01) and need for preventive care (OR=3.4, p<.01), compared with public hospitals. Microcredit members had a higher tendency towards utilization but membership effect pertained to the non- and moderately-poor. Compared with the patients who were non-members and the poorest, microcredit members who were non-poor had the highest likelihood (OR=7.46, p<.001) to visit MFI hospitals, followed by members with moderate income (OR=6.91, p<.001) and then non-members in non-poor households (OR=4.48, p<.01). Those who were members but the poorest had a negative association (OR=0.42), though not significant. Despite a higher utilization of preventive services in MFI hospitals, expenditure there was significantly higher. Qualitative probe found that, although public hospitals provided universal and low-cost care, the public sector suffered from insufficient workforce and infrastructure. In MFI hospitals charges were slightly cheaper than private clinics but much costlier than their public counterparts. To contain cost, MFI hospitals had highly flexible manpower arrangements. To generate income, MFI hospitals adopted proactive strategies to solicit desired patients. They not only selected patients through the pricing schedule but avoided complicated cases and left the poor patients to the public sector. Interviews also revealed that MFIs and government officers had divergent interpretations regarding complementarity and social responsibilities. While government officers expected collaboration at the field level and in prevention, MFIs opted for client segmentation. Finally, governing authorities were inconclusive about commercialization of MFI health programs. Conclusion: Inequity was more pronounced in MFI hospitals than public ones. By detaching themselves from the poor, the claims to serve the poor became rhetoric. The government, in addition to facilitating growth of MFIs, it seemed to take a laissez-faire policy with regards to MFIs’ hospital venture. Thus, using microcredit as a platform to deliver public goods or strengthen health system might not be a good idea without explicit policy guidance. The researcher suggested that health programs of MFIs be separated from the credit wing and reorganized toward primary health care to make care equitable and universally accessible. Hospital initiatives in the microfinance sector should be examined and regulated by both the health and microcredit regulatory authorities. This study holds practical implications for governments, development agencies and microfinance practitioners. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/4403 |
全文授權: | 同意授權(全球公開) |
顯示於系所單位: | 健康政策與管理研究所 |
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