原文链接：
https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(22)00206-7/fulltext
2009年至2019年，中国在政治和财政支持下实施了全面的卫生体系改革，加强公共卫生体系建设是改革的重点之一。尽管改革在一定程度上改善了公共卫生系统，但仍存在一些挑战，例如当前公共卫生系统的功能无法像预期一样，在组织和实施“健康中国倡议”方面发挥主导作用。新冠肺炎疫情进一步暴露了公共卫生系统的弱点和问题，使加强公共卫生系统建设成为需优先考虑的事项。
原文
01
Between 2009 and 2019, China implemented a comprehensive health system reform with strong political and financial supports, of which strengthening public health systems is one of the reform priorities. Although there is no doubt that the reform has improved public health systems to some extent, several challenges remain. For example, the function and capability of current public health systems cannot take the lead responsibility as expected in organising and implementing the Healthy China initiative.The COVID-19 outbreak revealed more weaknesses and problems with public health systems, making strengthening of public health systems an urgent priority.
中国的公共卫生问题一直面临着两个根本性挑战。
首先，医疗保健提供系统是彼此割裂的。卫生服务的组织者和提供者在为社区居民提供非传染性疾病和新冠肺炎等传染性疾病的卫生保健方面没有得到很好的协调。政府试图通过在县城和市区内建立医疗联盟来提高卫生服务的连续性，但仍需要整合的机制和时间。分散的医疗保健体系主要源于分散的融资体系，医疗保健提供者的资金来自四个渠道：社会卫生保险计划、政府定期卫生预算、基本公共卫生计划和患者自付。这些资金来源由不同的机构管理，在预算管理和分配方面缺乏有效的协调。医院和诊所不愿提供公共卫生保健，因为缺乏财政激励措施和相关法规要求，进一步造成了医疗体系和疾控体系的割裂。
第二，卫生支出以疾病为中心。“健康中国倡议”旨在将健康系统从以疾病为中心过渡到以公共卫生为中心，强调健康预防和促进的重要性。然而，要让这些改变发生并不容易，因为它需要公共政策的改变。在过去的十年里，人均卫生支出总额从2008年的人均1090元增加到2019年的人均4700元，增长了331%。尽管专业公共卫生组织支出的绝对数量增加了，但其在总卫生支出中的份额从2008年的8.58%下降到2019年的5.47%，更多的支出被用于医院。2012年至2017年，许多年轻的专业人员离开疾控中心，平均年离职率为0.5%；与此同时，医院相关部门的卫生专业人员的年增长率为6%。
原文
02
China's public health has been facing two fundamental challenges.
First, health-care delivery systems are fragmented. Health organisations and providers are not well coordinated in providing health care to community people for both non-communicable diseases and infectious diseases such as COVID-19 control. The government has tried to increase continuity of care by establishing medical alliances and groups within counties and cities, but integration mechanisms are needed, and it will take time to succeed. The fragmented health-care system mainly roots from the fragmented financing system. Health-care providers are financed through four channels: social health insurance schemes, regular government health budget, essential public health programmes, and out-of-pocket payments. These financial sources are managed by different authorities without effective coordination in budget management and allocation. Hospitals and clinics are reluctant to provide public health care due to the absence of financial incentives and the important number of regulations, which furthers separate hospitals and CDCs.
Second, health spending is disease centred. The Healthy China initiative aims to shift the health system from disease centred to public health centred, emphasising the importance of health prevention and promotion. However, it is not easy to make these changes happen, because it requires changes in public policies. Over the past decade, the total health expenditure increased from ¥1090 per capita in 2008 to ¥4700 per capita in 2019, increasing by 331%. But although the absolute amount of spending for specialised public health organisations increased, its share in total health expenditure declined from 8.58% in 2008 to 5.47% in 2019, as more spending was used in hospitals. Between 2012 and 2017, many young professionals left CDCs, with an average annual dropout rate of 0.5%; meanwhile, the hospital sector had a 6% annual increase rate of health professionals.
为了加强公共卫生系统，需要采取系统性的解决方法，重点关注三个方面的优先事项：治理、融资和服务。
首先，应加强有关当局和组织的公共卫生责任体系，以支持在政策中实施卫生工作。中央政府和地方政府都应对公共卫生系统的表现负责。应开发数字卫生系统以改进和评价公共卫生法规的实施。第二，利用战略采购机制分配卫生资源，公平和有效地利用卫生资金。在评估卫生资源分配的适当性时，可以探索一种面向公共健康的评估机制，优先提供预防性保健。应改变以医院为中心的融资系统，以支持预防保健和初级保健，这是卫生保健最具成本效益的投资方式。与此同时，当经济增长放缓（如新冠疫情期间）时，应确保卫生投资的持续供给。第三，应维持对初级保健系统的支持。我国政府已经采取多项措施改进三级卫生保健提供体系，包括加强初级卫生保健提供者的能力，以及协调各级卫生机构的发展和运作。这些措施的连续性至关重要，因为医疗保健提供系统的转变需要时间。
原文
03
To strengthen public health systems, a whole system approach needs to be adopted, focusing on three priorities: governance, financing, and service.
First, a responsibility system for public health by all related authorities and organisations should be strengthened to support implementation of health in all policies. Both central and local governments should be accountable for the performance of public health systems. Digital health systems should be developed to improve public health regulations and evaluations. Second, a strategic purchasing mechanism should be used for allocation and distribution of health resources. Health funds should be equitably and efficiently used. A public health-oriented evaluation mechanism in which provision of preventive care and health outcomes are prioritised could be explored in assessing appropriateness of health resources allocation. Hospital-centric financing systems should be changed to support preventive and primary care, which is the most cost-effective way to invest in health care. In the meantime, investment for health should be secured when economic growth is slowed (eg, by the COVID-19 pandemic). Third, support to a primary-care based system should be maintained. The government has made lots of efforts to improve the three tier health-care delivery system, including strengthening capacity of primary health-care providers and coordinating development and operation of different levels of health institutions. Continuity of the efforts is crucial because a shift in health-care delivery system takes time.
自新冠肺炎疫情爆发以来，加强公共卫生系统建设一直是中国卫生改革工作计划的核心。2022年，中央政府列出了加强公共卫生能力的四个工作重点，包括通过改善公共卫生专业人员能力建设公共卫生网络，加强疾病预防能力，协调卫生团队和机构共同管理肿瘤和中风等重大疾病，鼓励医院和临床医生使用适当的评价指标对健康教育水平进行评价和促进。加强公共卫生系统建设是在每个国家实现全民健康覆盖的关键。中国已经朝着正确的方向前进，通过继续努力，未来可能会有一个更强大的公共卫生体系。
原文
04
Strengthening public health systems has been central to China's health reform workplans since the COVID-19 outbreak. In 2022, the central government listed four work priorities for strengthening public health capacity, including strengthening capacity of disease prevention by improving the network of disease prevention and capacity building of public health professionals, coordinating health teams and institutions working together for managing major diseases such as cancer and strokes, and incentivising hospitals and clinicians to provide health education and promotion by using appropriate evaluation indicators.
转自：“中国全科医学学术平台”微信公众号
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