### 公式拨款和买方-供方体系

```公式拨款和买方-供方体系
Performance Budgeting Course,
APFDC, Shanghai, October 2010

APFDC，上海，2010年10月
Prepared by Marc Robinson
1

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Two mechanisms for creating tighter funding/results
◦ Formula funding (FF) 公式拨款
◦ Purchaser-provider (PP) 买方-供方
◦ PP is a type of FF system 买方-供方是公式拨款体系的一种
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Explain how these systems work 解释这些体系如何运行

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Limitations

◦ Risk of perverse effects 产生负面效果的风险
◦ Appropriate for only some types of government services

◦ Not techniques for government-wide budgeting

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3

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Suppose unit cost of vaccinations is \$25

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Use unit cost of vaccinations in budget

◦ Provide \$1m vaccination funding to ministry

◦ Indicate that expect 40,000 vaccinations 指出预期接种疫苗4万例
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Makes performance expectations explicit

◦ Like setting a performance target 如 设置绩效目标
◦ Hold ministry accountable if fewer vaccinations

4

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Funding determined by formula

◦ Based on, e.g., population, services provided, size of geographic
area served

◦ Partially or wholly formula-based 部分或全部基于公式
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Performance budgeting form of FF: 公式拨款的绩效预算形式
◦ Formula links funding to results 公式将拨款和结果联系起来
 Outputs or outcomes 产出或结果
◦ And aim is to promote better results 目的是改善结果
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Quantity x Unit Cost = Budget

5

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Different funding for different outputs

◦ E.g. in university funding systems 如 大学拨款体系
◦ Funding for science students different from that of humanities
students 给理科学生的拨款不同于给文科学生的
◦ Science much more resource intensive

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Simple unit cost funding formula

◦ Funding = output quantity x unit cost 拨款=产出数量 x 单位成本
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Rarely as simple as that

6

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Danish “Taximeter” system example

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Course completion payments

◦ The results-based element 结果导向的要素
◦ Vary with course types 随行程类型而变化
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But other elements in funding system:

◦ Building and maintenance component 创立和维护的部分
◦ Collective expenses (overheads) component 共有开支部分
◦ Supplementary grants for small institutions

◦ And a range of other payments… 以及一系列其他支付
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Universities funded for courses provided

◦ As main funding mechanism 作为主要的拨款机制
◦ E.g. \$3000 per year for full time law student

◦ \$5000 per year for science student 理科学生每年拨款5000美元
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Money linked to students actually taught

◦ Not to numbers planned to be taught 而非计划要教的学生数
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Incentive for output delivery & efficiency对完成产出和效率的

◦ High cost universities suffer 大学承担的高昂成本
◦ Incentive to actually deliver planned outputs

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Type of cost-based FF system 基于成本的公式拨款体系的类型
Funding for outputs actually delivered 按实际完成产出拨款
◦ Not for planned outputs 不是计划产出
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Usually funding for outputs, not outcomes

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Government purchases outputs

◦ From provider agency 从供应部门来看
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Main funding source

◦ Not just supplementary bonus funding 不只是补充性的奖励基金
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Incentive to boost output quantity 对提高产出量的激励
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Agencies paid prices for outputs 部门为产出支付价格
◦ Might also be some non-output funding

◦ E.g. separate capital funding 如，独立投资基金
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Loss if agency’s unit costs > price

◦ Incentive to improve efficiency 对改善效率的激励
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Payment only for outputs produced

◦ Less output means less funding 较少的产出意味着较少的拨款
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The closer prices are to efficient cost

◦ The greater the pressure for efficiency 改善效率的压力就会越大
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Price

Unit cost 单位成本
X quantity 数量
Total revenue 总收入

How to fund?
Loss 损失
Total costs of production 总生产成本
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The principle of simple markets

◦ Purchasers pay prices to arms-length suppliers

◦ Revenue only earned for products delivered

◦ Loss if products aren’t supplied

◦ Loss for inefficiency 因低效而遭受的损失
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PP also called quasi-market mechanism

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Payment to hospital for outputs 对医院产出的拨款
Based on Diagnostic-Related Groups (DRGs)

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Prices for each DRG category

◦ \$x for hip/knee replacement 置换髋关节或膝关节的价格为x美元
◦ \$y for heart transplant 心脏移植的价格为y美元
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Funding depends on output 拨款取决于产出
Losses if costs exceed DRG price

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Market (purchaser-provider) principle 市场（买方-供方）原则
Replaces “block” budgets 代替“整体”预算
◦ Funding like that of ministries 像政府部门那样的拨款

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Improved efficiency

◦ Pressure to deliver services at lower cost 以低成本提供服务的压力
◦ Increased specialization 提高专业化
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Timeliness of treatment

◦ Only earn money when treatment provided 只有提供治疗才能赚钱
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Patient choice 患者的选择
◦ Funding follows the patient 拨款遵照病人的选择
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Equitable funding of hospitals

◦ Relative to block budgets 相对于整体预算
◦ Where funding poorly related to output

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Skimping 克扣行为
◦ Cost-cutting at expense of quality 以牺牲质量为代价削减成本
◦ E.g. use of inferior but cheaper prostheses 如使用廉价劣质的假肢
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Dumping 推卸行为
◦ Avoiding expected higher cost patients

◦ Result of heterogeneity 异质性结果
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Creaming 揩油行为
◦ Actively selecting expected low cost cases

◦ Heterogeneity again 也是异质性
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Considerable professional resistance 相当多专业性的阻力

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Important role of medical ethics

◦ Practitioner power over treatment choices

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Public hospitals not profit-seekers 公立医院不以追求利润为目的
◦ Loss-avoiders 损失规避方
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Quality assurance systems

◦ Peer review, accreditation etc 同行审查，认证等
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No right to refuse to treat patients 无权拒绝治疗病人
Addition of quality element to payment?

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PP model for whole government budget

◦ Applied to ministries, not just NPIs

◦ New Zealand, mid-1990s 新西兰，20世纪90年代中期
◦ Australia, late 1990s 澳大利亚，20世纪90年代晚期
◦ Now abandoned... serious failure 现在已经放弃...严重失灵
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Ministries receive prices for outputs 政府部门接受产出价格
◦ Govt to act as a “purchaser” of their services

◦ Budget documents or supporting material to state output
deliverables用于说明可交付产出的预算文件和相关材料
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Aim to introduce payment for results

◦ Revenue only earned when outputs delivered

◦ Quarterly invoicing in Victoria, Australia

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Aims to set price = efficient cost

◦ Simulate operation of a competitive market

◦ Efficient cost supposed to be determined by market comparators,
market testing etc... 效率成本应该由市场参比和市场测试等来决定
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Efficiency pressure on ministries 提高政府部门效率的压力
◦ Pressure to deliver outputs 交付产出的压力
◦ Pressure to reduce costs to efficient level

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Facilitate competition with private sector suppliers

◦ Ministries would be treated exactly like external suppliers

◦ Tenders would be held on equal footing

◦ Would loose the work if the private sector could supply more
cheaply

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Unworkable for many services 该系统对许多服务不适用
◦ Police, defence, fire services, foreign affairs etc

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Never succeeded in basing prices on efficient cost

◦ Too difficult to determine 设定价格的难度太大
◦ Required detailed research 需要详细的研究
◦ Still difficult if no market comparator

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Services where unit cost varies greatly 单位成本变化较大的服务
◦ Because of tailoring of service to customer/case characteristics

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FF/PP can manage some heterogeneity

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If average unit cost is stable

◦ Some clients/cases cost more than others

◦ But it averages out 但是达到平均水平
◦ Approximately true for hospital services 医院的服务大约就是这样
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But many public services with severe heterogeneity

◦ No stable average unit cost 平均单位成本不固定
◦ Can’t apply a cost-based funding formula 不能运用基于成本的拨款公式
23

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Example of fire services: 消防服务例子
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Unpredictable demand for services 服务需求无法预料
Must be responded to immediately 必须立即作出响应
Spare response capacity maintained 维持一定备用响应能力
Relation between funding and services actually provided is
therefore weak因此拨款和实际提供服务之间的关系较弱
Can’t fund on output formula 不能按产出公式拨款
Many services like this in government

◦ Insurance-type services 保险型服务
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Selective rather than general application

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Apply only to right types of programs

◦ Relatively standardized services 相对标准化的服务
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Complexity involved in setting formula

◦ Argument for gradualism and selectiveness

◦ Focus on one or two major services areas

◦ Rather than immediately introducing in many areas

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FF and PP valuable performance budgeting tools

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Should be selectively applied 应该有选择地应用
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Technically demanding to implement

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Developing countries

◦ Need to be particularly selective 特别需要有选择地应用
◦ Very gradual approach to use of these tool

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