英國國民健康服務的發展(1948-1996)－臺灣全民健康保險的借鏡與啓示

The Development of Britain's National Health Service 1948-1996-Lessons and Implications for Taiwan's National Health Insurance

黃源協(Yuan-Shie Hwang)

《社會政策與社會工作學刊》 1卷1期 (1997/06) Pp. 99-132

https://doi.org/10.6785/SPSW.199706.0099

摘要

NHS開辦後，第一次財政危機便接踵而來，五○年代初期，兩大政黨皆曾採取部分負擔及總額預算方式應付之，保守黨政府更企圖要再折回到NHI的體系，唯因民衆對NHS的依賴與期待及社會主義團體的強烈反對，而使得此企圖未能得逞。受惠於戰後經濟的復甦與繁榮，六○年代及七○年代中期前，NHS皆能在穩定中成長與發展。七○年代中期的石油危機，使得NHS面臨第二次的財政困境，保守黨於一九七九年執政後，經營效率的改善便被視為是舒緩財政壓力的主要策略，「總體經營」及「內部市場」的實施，即為實現此策略的具體措施。唯因前者缺乏市場的誘因及無法擺脫政治的影響，後者需大量的行政費用及NHS所強調的公平性遭受侵犯，而使得改革蒙上陰影。
英國健康照護體系的發展，可提供臺灣全民健保多項重要的借鏡或啓示。就健政策的制定而言，健照護議題本是政治議題，讓「政治歸政治、醫療歸醫療」的理想，必難以達成，因而政策的制定應將政治現實視為重要變項。就財源籌措而言，健康照護財務自主的理想雖不易實現，但若能適時且斷然的採取有效策略加以防範，則健康照護的財務支出不必然會是個無底洞。就服務的經營而言，「公辦民營」雖可提昇效率，但若認為它能完全解決健康服務的爭端及免除政府的責任，必是一廂情願的想法。

關鍵字

國民健康服務 ； 總體經營 ； 內部市場

並列摘要

Shortly after the implementation of the NHS in 1948, to cope with its first financial crisis, various charges and global budget were introduced by both main parties. Furthermore, the Conservatives ever tried to convert the taxation-based health care system to a contributory one. The ambitious programme was finally abandoned as a result of its unpopularity and fierce opposition from the Labour Party. Benefited from the economic prosperity in the 1960s and early 1970s, the NHS's resources were increased steadily. However, the oil crisis of the mid1970s brought the NHS into its second financial crisis. For coping with the difficulties, promoting efficiency has been regarded as one of main solutions by the Conservatives. 'General management' and 'internal market' have therefore been introduced and carried out. The former has not achieved its goals as expected partly due to absence of incentive and inability to get rid of political intervention, and the latter has suffered from serious condemnation as a result of the increase in management cost and the creation of a 'two tier health service'.
There have been several lessons or implications for Taiwan's NHI. First of all, any health policy-makings should take political institutions in which they take place into consideration because health issues essentially are political issues. Secondly, health care expenditure does not necessarily mean a bottomless pit if proper measures could be implemented timely. Finally, even though privatisation is good for promoting efficiency, it does not mean or guarantee that government could be entirely exempted from the responsibility for health financing.

並列關鍵字

national health service ； general management ； internal market