中国公开2009年度最新医改方案(全文)

新闻中国 - 四月 29, 2009 - 来源:单点日志 - No Comments -

按照党的十七大精神,为建立中国特色的医药卫生体制,逐步实现人人享有基本医疗卫生服务的目标,提高全民健康水平,现就改革提出如下意见。
  
一、充分认识深化医药卫生体制改革的重要性、紧迫性和艰巨性健康是人全面发展的基础。
医药卫生事业关系千家万户幸福,是重大民生问题。深化医药卫生体制改革,加快医药卫生事业发展,适应人民群众日益增长的医药卫生需求,不断提高人民群众健康素质,是贯彻落实科学发展观、促进经济和社会全面协调可持续发展的必然要求,是维护社会公平正义的重要举措,是人民生活质量改善的重要标志,是全面建设小康社会和构建社会主义和谐社会的一项重大任务。
新中国成立以来,特别是改革开放以来,我国医药卫生事业取得了显着成就,覆盖城乡的医药卫生服务体系基本形成,疾病防治能力不断增强,医疗保障覆盖人口逐步扩大,卫生科技水平迅速提高,人民群众健康水平明显改善,居民主要健康指标处于发展中国家前列。尤其是抗击”非典”取得重大胜利以来,各级政府加大投入,公共卫生、农村医疗卫生和城市社区卫生加快发展,新型农村合作医疗和城镇居民基本医疗保险取得突破性进展,为深化医药卫生体制改革打下了良好基础。
同时,也应该看到,当前我国医药卫生事业发展水平与经济社会协调发展要求和人民群众健康需求不适应的矛盾还比较突出。城乡和区域医疗卫生事业发展不平衡,资源配置不合理,公共卫生和农村、社区医疗卫生工作比较薄弱,医疗保障制度不健全,药品生产流通秩序不规范,医院管理体制和运行机制不完善,政府卫生投入不足,医药费用上涨过快,人民群众反映比较强烈。从现在到2020年,是我国全面建设小康社会的关键时期,医药卫生工作肩负着繁重的任务。随着经济的发展和人民生活水平的提高,群众对改善医药卫生服务将会有更高的要求。工业化、城镇化、人口老龄化、疾病谱变化和生态环境变化等,都给医药卫生工作带来一系列新的严峻挑战。
深化医药卫生体制改革,是加快医药卫生事业发展的战略选择,是实现人民共享改革发展成果的重要途径,是广大人民群众的迫切愿望。医药是一项涉及面广、难度大的社会系统工程。我国人口多,人均收入水平低,城乡、区域差距大,长期处于社会主义初级阶段的基本国情,决定了深化医药卫生体制改革是一项十分复杂艰巨的任务,是一个渐进的过程,需要在明确方向和框架的基础上,经过长期艰苦努力和坚持不懈的探索,才能逐步建立符合我国国情的医药卫生体制。
  
二、医药体制改革的指导思想、基本原则和总体目标
(一)指导思想。医药体制改革的指导思想是:以邓小平理论和”三个代表”重要思想为指导,深入贯彻落实科学发展观,从我国国情出发,借鉴国际有益经验,着眼于实现人人享有基本医疗卫生服务的目标,着力解决人民群众最关心、最直接、最现实的利益问题。坚持公共医疗卫生的公益性质,坚持预防为主、以农村为重点、中西医并重的方针,实行政事分开、管办分开、医药分开、营利性和非营利性分开,强化政府责任和投入,完善国民健康政策,健全制度体系,加强监督管理,创新体制机制,鼓励社会参与,建设覆盖城乡居民的基本医疗卫生制度,不断提高全民健康水平,促进社会和谐。
  
(二)基本原则。医药体制改革应遵循以下基本原则:坚持以人为本,把维护人民健康权益放在第一位。坚持医药卫生事业为人民健康服务的宗旨,以保障人民健康为中心,以人人享有基本医疗卫生服务为根本出发点和落脚点,从改革方案设计、卫生制度建立到服务体系建设都要遵循公益性的原则,着力解决群众反映强烈的突出问题,努力实现全体人民病有所医。坚持立足国情,建立中国特色的医药卫生体制。坚持从我国的基本国情出发,实事求是地总结医药卫生事业改革发展的实践经验,准确把握医药卫生发展规律和主要矛盾;坚持基本医疗卫生服务水平与国民经济和社会发展相协调、与人民群众的承受能力相适应;充分发挥中医药作用;坚持因地制宜、分类指导,发挥地方积极性,探索建立符合国情的基本医疗卫生制度。坚持公平效率统一,政府主导与发挥市场机制作用相结合。坚持政府主导,强化政府在基本医疗卫生制度中的责任,加强政府在制度、规划、筹资、服务、监管等方面的职责,维护公共医疗卫生的公益性,促进公平公正;同时,注重发挥市场机制作用,促进有序竞争机制的形成,提高医疗卫生运行效率和服务水平、质量,满足人民群众多层次、多样化的医疗卫生需求。坚持统筹兼顾,把完善制度体系与解决当前突出问题结合起来。从全局出发,兼顾供给方和需求方等各方利益,注重预防、治疗、康复三者的结合,正确处理政府、卫生机构、医药企业、医务人员和人民群众之间的关系。既着眼长远,创新体制机制,又立足当前,着力解决医药卫生中存在的突出问题;既注重整体设计,明确总体改革方向目标和基本框架,又突出重点,分步实施,积极稳妥地推进改革。


  
(三)总体目标。医药体制改革的总体目标是:建立覆盖城乡居民的基本医疗卫生制度,为群众提供安全、有效、方便、价廉的医疗卫生服务。到 2020年,覆盖城乡居民的基本医疗卫生制度基本建立。普遍建立比较完善的公共卫生服务体系和医疗服务体系,比较健全的医疗保障体系,比较规范的药品供应保障体系,比较科学的医疗卫生机构管理体制和运行机制,形成多元办医格局,人人享有基本医疗卫生服务,基本适应人民群众多层次的医疗卫生需求,人民群众健康水平进一步提高。三、完善医药卫生四大体系,建立覆盖城乡居民的基本医疗卫生制度建立覆盖城乡居民的公共卫生服务体系、医疗服务体系、医疗保障体系、药品供应保障体系四位一体的基本医疗卫生制度,四大体系相辅相成,配套建设,协调发展。
  
(四)全面加强公共卫生服务体系建设。建立健全疾病预防控制、健康教育、妇幼保健、精神卫生、应急救治、采供血、卫生监督和计划生育等专业公共卫生服务网络,并完善以基层医疗卫生服务网络为基础的医疗服务体系的公共卫生服务功能,建立分工明确、信息互通、资源共享、协调互动的公共卫生服务体系,提高公共卫生服务能力和突发公共卫生事件应急处置能力,促进城乡居民逐步享有均等化的基本公共卫生服务。确定公共卫生服务范围。明确国家公共卫生服务项目,逐步增加服务内容,细化服务和考核标准。鼓励地方政府根据当地经济水平和突出的公共卫生问题,在中央规定服务项目的基础上增加公共卫生服务内容。完善公共卫生服务体系。进一步明确公共卫生服务体系的职能、目标和任务,优化人员和设备配置,探索整合公共卫生服务资源的有效形式。完善重大疾病防控体系和突发公共卫生事件应急机制,加强对严重威胁人民健康的传染病、地方病、职业病和慢性病等疾病的预防控制和监测。加强城乡急救体系建设。加强健康促进与教育。医疗卫生机构及机关、学校、社区、企业等要大力开展健康教育,倡导健康文明的生活方式,利用广播、电视、网络、报刊杂志等媒体,加强健康、医药卫生知识的传播,促进公众合理营养,提高广大人民群众的健康意识和自我保健能力。深入开展爱国卫生运动。将农村环境卫生与环境污染治理纳入社会主义新农村建设规划,推动卫生城市和文明村镇建设,不断改善城乡居民的生活、工作等方面的卫生环境。加强卫生监督服务。大力促进环境卫生、食品卫生、职业卫生、学校卫生和农民工卫生工作。
  
(五)进一步完善医疗服务体系。坚持非营利性医疗机构为主体、营利性医疗机构为补充,公立医疗机构为主导、非公立医疗机构共同发展的办医原则,建设结构合理、分工明确、防治结合、技术适宜、运转有序,包括覆盖城乡的基层医疗卫生服务网络和各类医院在内的医疗服务体系。大力发展农村医疗卫生服务体系。加快建立健全以县级医院为龙头、乡镇卫生院为骨干、村卫生室为基础的农村三级医疗卫生服务网络。县级医院作为县域内的医疗卫生中心,主要负责以住院为主的基本医疗服务及危重急症病人的抢救,并承担对乡村卫生机构的业务技术指导和乡村卫生人员的进修培训;乡镇卫生院负责提供公共卫生服务和常见病、多发病的诊疗等综合服务,并承担对村卫生室的业务管理和技术指导等工作;村卫生室承担行政村的公共卫生服务及一般疾病的诊治等工作。有条件的农村可以实行乡村一体化管理。加快实施农村卫生服务体系建设与发展规划,积极推进农村医疗卫生基础设施和能力建设,政府重点办好县级医院并在每个乡镇办好一所卫生院,采取多种形式支持村卫生室建设,大力改善农村医疗卫生条件,提高医疗卫生服务质量。完善以社区卫生服务为基础的新型城市医疗卫生服务体系。大力发展社区卫生服务,加快建设以社区卫生服务中心为主体的城市社区卫生服务网络,完善社区卫生服务功能,以维护社区居民健康为中心,提供疾病预防控制等公共卫生服务和一般常见病、多发病、慢性病的初级诊疗服务。转变社区卫生服务模式,坚持主动服务、上门服务,逐步承担起居民健康”守门人”的职责。健全各类医院的功能和职责。优化医院布局和结构,充分发挥城市医院在急危重症和疑难病症的诊疗、医学教育和科研、指导和培训基层卫生人员等方面的骨干作用。有条件的大医院按照区域卫生规划要求,可以通过托管、重组等方式促进医疗资源合理流动。建立城市医院与社区卫生服务机构的分工协作机制。城市医院通过技术支持、人员培训等方式,带动社区卫生健康持续发展。同时,采取改善服务能力、降低收费标准、提高报销比例等综合措施,引导一般诊疗下沉到基层,逐步实现社区首诊、分级医疗和双向转诊。整合城市卫生资源,充分利用城市现有一、二级医院及国有企事业所属医疗机构等基层医疗资源,发展和完善社区卫生服务网络。充分发挥包括民族医药在内的中医药在疾病预防控制、应对突发公共卫生事件、医疗服务中的作用。加强中医临床研究基地和中医院建设,组织开展中医药防治疑难疾病的联合攻关,在医疗卫生机构中大力推广中医药适宜技术。创造良好的政策环境,扶持中医药发展,促进中医药继承和创新。建立城市医院对口支援农村医疗卫生工作的制度。发达地区要加强对口支援贫困地区和少数民族地区发展医疗卫生事业。城市大医院要与贫困地区和少数民族地区的县级医院建立长期稳定的对口支援和合作制度,采取临床服务、人员培训、技术指导、设备支援等方式,帮助其提高医疗水平和服务能力。
  
(六)加快建设医疗保障体系。加快建立和完善以基本医疗保障为主体,其他多种形式补充医疗保险和商业健康保险为补充,覆盖城乡居民的多层次医疗保障体系。建立覆盖城乡居民的基本医疗保障体系。城镇职工基本医疗保险、城镇居民基本医疗保险、新型农村合作医疗和城乡医疗救助共同组成基本医疗保障体系,分别覆盖城镇就业人口、城镇非就业人口、农村人口和城乡困难人群。坚持广覆盖、保基本、可持续的原则,从重点保障大病起步,逐步向门诊小病延伸,提高保障水平。建立国家、单位、家庭和个人责任明确、分担合理的多渠道筹资机制,实现社会互助共济。随着经济社会发展,逐步提高筹资水平和统筹层次,缩小保障水平差距,最终实现制度框架的基本统一。进一步完善城镇职工基本医疗保险制度,加快覆盖就业人口,重点解决国有关闭破产企业、困难企业等职工和退休人员以及混合所有制、非公有制经济组织从业人员和灵活就业人员的医疗保险问题;加快推进城镇居民基本医疗保险试点,到2009年全面推开,重视解决老人和儿童的基本医疗保险问题;全面实施新型农村合作医疗制度,逐步提高政府补助水平,适当增加农民缴费,提高保障能力。完善城乡医疗救助制度。对困难人群参保及其难以负担的医疗费用提供补助,筑牢医疗保障底线。有条件的地区要采取多种方式积极探索建立城乡一体化的基本医疗保障管理体系。鼓励工会等社会团体开展多种形式的医疗互助活动。鼓励和引导各类公益性组织发展社会慈善医疗救助。做好城镇职工基本医疗保险制度、城镇居民基本医疗保险制度、新型农村合作医疗制度和城乡医疗救助制度之间的衔接,妥善解决农民工基本医疗保险问题。签订劳动合同并与企业建立稳定劳动关系的农民工,要按照国家规定明确用人单位缴费责任,将其纳入城镇职工基本医疗保险制度;其他农民工根据实际情况,参加户籍所在地新型农村合作医疗或务工所在地城镇居民基本医疗保险。积极做好农民工医保关系接续、异地就医和费用结算服务等政策衔接。积极发展商业健康保险。鼓励商业保险机构开发适应不同需要的健康保险产品,简化理赔手续,方便群众,满足多样化的健康需求。鼓励企业和个人通过参加商业保险及多种形式的补充保险解决基本医疗保障之外的需求。继续探索商业保险机构参与新型农村合作医疗等经办管理的方式。
  
(七)建立健全药品供应保障体系。以建立国家基本药物制度为基础,以培育具有国际竞争力的医药产业、提高药品生产流通企业集中度、规范药品生产流通秩序、完善药品价格形成机制、加强政府监管为主要内容,建设规范化、集约化的药品供应保障体系,不断完善执业药师制度,保障人民群众安全用药。建立国家基本药物制度。中央政府统一制定和发布国家基本药物目录,按照防治必需、安全有效、价格合理、使用方便、中西药并重的原则,结合我国用药特点,参照国际经验,合理确定我国基本药物品种和数量。建立基本药物的生产供应体系,在政府宏观调控下充分发挥市场机制的作用,基本药物由国家实行招标定点生产或集中采购,直接配送,减少中间环节,在合理确定生产环节利润水平的基础上统一制定零售价,确保基本药物的生产供应,保障群众基本用药。规范基本药物使用,制订基本药物使用规范和临床应用指南。城市社区卫生服务中心(站)、乡镇卫生院、村卫生室等基层医疗卫生机构应全部使用基本药物,其他各类医疗机构也要将基本药物作为首选药物并确定使用比例。基本药物全部纳入基本医疗保障体系药物报销目录,报销比例明显高于非基本药物规范药品生产流通。完善医药产业发展政策和行业发展规划,严格市场准入,严格药品注册审批,大力规范和整顿生产流通秩序,推动医药产业优化升级和技术进步,发展药品现代物流和连锁经营,促进药品生产、流通企业的整合。建立覆盖面广、体系健全、便民惠农的农村药品供应网和监督网。支持用量小的特殊用药、急救用药生产。完善药品储备制度。规范药品采购,坚决治理医药购销中的商业贿赂。加强药品不良反应监测,建立药品安全预警机制和应急处置机制。四、完善体制机制,保障医药卫生体系有效规范运转完善医药卫生的管理、运行、投入、价格、监管体制机制,加强科技与人才、信息、法制建设,保障医药卫生体系有效规范运转。
  
(八)建立协调统一的医药卫生管理体制。按照政事分开、管办分开、属地化和全行业管理的原则,合理确定不同层级政府之间、政府与医药卫生机构之间的职责范围,形成职能明确、定位清晰、综合协调、权责统一的管理体制。实施属地化和全行业管理。所有医疗卫生机构,不论所有制、投资主体、隶属关系和经营性质,均由所在地卫生行政部门实行统一规划、统一准入、统一监管。中央、省级可以设置少量承担医学科研、教学功能的医学中心或区域医疗中心、承担全国或区域性疑难病症诊治的专科医院等医疗机构;县(市、区)主要负责举办县级医院、乡村卫生和社区卫生机构;其余公立医院由设区的市负责举办。强化区域卫生规划。省级人民政府制定卫生资源配置标准,组织编制区域卫生规划和医疗机构设置规划,明确医疗机构的数量、规模、布局和功能。科学制定乡镇卫生院(村卫生室)、社区卫生服务中心(站)等基层卫生机构和各级医院建设和设备配置标准。充分利用和优化配置现有医疗卫生资源,调整优化结构和布局,对不符合规划要求的医疗机构要逐步进行整合,严格控制大型医疗设备配置,鼓励共建共享,提高医疗卫生资源利用效率。新增卫生资源必须符合区域卫生规划,重点投向农村和社区卫生等薄弱环节。加强区域卫生规划与城市发展规划、土地利用规划等的衔接。建立区域卫生规划和资源配置监督评价机制。推进公立医院管理体制改革。从有利于强化公立医院公益性和政府有效监管出发,积极探索政事分开、管办分开的多种实现形式。进一步转变政府职能,卫生行政部门主要承担卫生发展规划、资格准入、规范标准、服务监管等行业管理职能,其他有关部门按照各自职能进行管理和提供服务。落实公立医院独立法人地位。进一步完善基本医疗保险管理体制。中央统一制定基本医疗保险制度框架和政策,地方政府负责组织实施管理,创造条件逐步提高统筹层次。有效整合基本医疗保险经办资源,逐步实现城乡基本医疗保险行政管理的统一。
  
(九)建立高效规范的医药卫生机构运行机制。以维护公立医疗卫生机构公益性质为核心,逐步建立规范、科学、高效、有序的医药卫生机构运行机制。公共卫生机构收支全部纳入预算管理。按照承担的职责任务,由政府合理确定人员编制、工资水平和经费标准,明确各类人员岗位职责,严格人员准入,加强绩效考核,建立能进能出的用人制度,提高工作效率和服务质量。转变基层医疗卫生机构运行机制。政府举办的城市社区卫生服务中心(站)和乡镇卫生院等基层医疗卫生机构,要严格界定服务功能,明确规定使用适宜技术、适宜人才、适宜设备和基本药物,为广大群众提供低成本服务,维护公益性质。要严格核定人员编制,实行人员聘用制,建立能进能出和激励有效的人力资源管理制度。要明确收支范围和标准,实行核定任务、核定收支、绩效考核补助的财务管理办法,并探索实行收支两条线、公共卫生和医疗保障经费的总额预付等多种行之有效的管理办法,严格收支预算管理,提高资金使用效益。要改革药品加成政策,实行药品零差率销售。加强和完善内部管理,建立以服务质量为核心、以岗位责任与绩效为基础的考核和激励制度,形成保障公平效率的长效机制建立规范的公立医院运行机制。公立医院要遵循公益性质和社会效益原则,坚持以病人为中心,优化服务流程,规范用药检查和医疗行为,深化运行机制改革。建立和完善医院法人治理结构,明确所有者和管理者的责权,形成决策、执行、监督相互制衡,有责任、有激励、有约束、有竞争、有活力的机制。实行医药收支分开管理,探索有效方式逐步改革以药补医机制。通过实行药品购销差别加价、设立药事服务费等多种方式逐步改革或取消药品加成政策,同时采取适当调整医疗服务价格、增加政府投入、改革支付方式等措施完善公立医院补偿机制。进一步完善财务、会计管理制度,严格预算管理,加强财务监管和运行监督。地方可结合本地实际,对有条件的医院开展”核定收支、以收抵支、超收上缴、差额补助、奖惩分明”等多种管理办法的试点。改革人事制度,完善分配激励机制,推行聘用制度和岗位管理制度,严格工资总额管理,实行以服务质量及岗位工作量为主的综合绩效考核和岗位绩效工资制度,有效调动医务人员的积极性。健全医疗保险经办机构运行机制。完善内部治理结构,建立合理的用人机制和分配制度,完善激励约束机制,提高医疗保险经办管理能力和管理效率。
  
(十)建立政府主导的多元卫生投入机制。明确政府、社会与个人的投入责任,确立政府在提供公共卫生和基本医疗服务中的主导地位。公共卫生服务主要通过政府筹资,向城乡居民均等化提供。基本医疗服务由政府、社会和个人三方合理分担费用。特需医疗服务由个人直接付费或通过商业健康保险支付。建立和完善政府卫生投入机制。中央政府和地方政府都要增加对卫生的投入,并兼顾供给方和需求方。逐步提高政府卫生投入占卫生总费用的比重,使居民个人基本医疗卫生费用负担明显减轻;政府卫生投入增长幅度要高于经常性财政支出的增长幅度,使政府卫生投入占经常性财政支出的比重逐步提高。新增政府投入重点用于支持公共卫生、农村卫生、城市社区卫生和基本医疗保障。按照分级负担的原则合理划分中央和地方各级政府卫生投入责任。地方政府承担主要责任,中央政府主要对国家免疫规划、跨地区的重大传染疾病预防控制等公共卫生、城乡居民的基本医疗保障以及有关公立医疗卫生机构建设等给予补助。加大中央、省级财政对困难地区的专项转移支付力度。完善政府对公共卫生的投入机制。专业公共卫生服务机构的人员经费、发展建设和业务经费由政府全额安排,按照规定取得的服务收入上缴财政专户或纳入预算管理。逐步提高人均公共卫生经费,健全公共卫生服务经费保障机制。完善政府对城乡基层医疗卫生机构的投入机制。政府负责其举办的乡镇卫生院、城市社区卫生服务中心(站)按国家规定核定的基本建设、设备购置、人员经费和其承担公共卫生服务的业务经费,使其正常运行。对包括社会力量举办的所有乡镇卫生院和城市社区卫生服务机构,各地都可采取购买服务等方式核定政补助。支持村卫生室建设,对乡村医生承担的公共卫生服务等任务给予合理补助。落实公立医院政府补助政策。逐步加大政府投入,主要用于基本建设和设备购置,扶持重点学科发展,符合国家规定的离退休人员费用和补贴政策性亏损等,对承担的公共卫生服务等任务给予专项补助,形成规范合理的公立医院政府投入机制。对中医院、传染病院、精神病院、妇幼保健院和儿童医院等在投入政策上予以倾斜。严格控制公立医院建设规模、标准和贷款行为。完善政府对基本医疗保障的投入机制。政府提供必要的资金支持新型农村合作医疗、城镇居民基本医疗保险、城镇职工基本医疗保险和城乡医疗救助制度的建立和完善。保证相关经办机构正常经费。鼓励和引导社会资本发展医疗卫生事业。积极促进非公医疗卫生机构发展,形成投资主体多元化、投资方式多样化的办医体制。抓紧制订和完善有关政策法规,规范社会办医疗机构包括外资办医疗机构的准入条件,完善公平公正的行业管理政策。鼓励社会资金依法兴办非营利性医疗机构。国家制定公立医院改制的指导性意见,积极引导社会资金以多种方式参与包括国有企业所办医院在内的部分公立医院改制重组。稳步推进公立医院改制的试点,适度降低公立医疗机构比重,形成公立医院与非公立医院相互促进、共同发展的格局。支持有资质人员依法开业,方便群众就医。完善医疗机构分类管理政策和税收优惠政策。依法加强对社会办医的监管。大力发展慈善事业。制定相关优惠政策,鼓励社会力量兴办慈善医疗机构,或向医疗救助、医疗机构等慈善捐赠。
  
(十一)建立科学合理的医药价格形成机制。完善政府调控与市场调节相结合、客观反映市场供求情况和生产服务成本变化的医疗服务和药品价格形成机制。规范医疗服务价格管理。对非营利性医疗机构提供的基本医疗服务,实行政府指导价,其余由医疗机构自主定价。中央政府负责制定医疗服务价格政策及项目、定价原则及方法;省或市级价格主管部门会同卫生、劳动保障部门核定基本医疗服务指导价格。基本医疗服务价格按照扣除财政补助的服务成本制定,体现医疗服务成本和技术劳务价值。不同级别的医疗机构和医生提供的服务,实行分级定价。规范公立医疗机构收费项目和标准,研究探索按病种等收费方式改革。建立医用检查治疗设备仪器价格监测、服务成本监审和服务价格定期调整制度。改革药品价格形成机制。合理调整政府定价范围,改进药品定价方法,利用价格杠杆鼓励企业自主创新,促进国家基本药物的生产和使用。对新药和专利药品逐步实行上市前药物经济性评价制度。对仿制药品实行后上市价格从低定价制度,抑制低水平重复建设。推行在药品外包装上标示价格制度。严格控制药品流通环节差价率。对医院销售药品开展差别加价、收取药事服务费等试点,引导医院合理用药。加强医用耗材及植(介)入类医疗器械流通和使用环节价格的控制和管理。健全医药价格监测体系,规范企业自主定价行为。积极探索建立医疗保险经办机构与医疗机构、药品供应商的谈判机制,发挥医疗保障对医疗服务和药品费用的制约作用。
  
(十二)建立严格有效的医药卫生监管体制。完善监管网络,强化监管职责,创新监管手段,提高依法监管能力,逐步建立政府为主体、社会多方参与的监管体制强化医疗卫生监管。健全卫生监督执法体系,加强卫生监督机构能力建设。加强医疗卫生服务行为和质量监管,完善医疗卫生服务标准和质量评价体系,规范管理制度和工作流程,加快制定统一的疾病诊疗规范,健全医疗卫生服务质量监测网络。加强医疗卫生机构的准入和运行监管。加强对生活饮用水、职业卫生、食品安全等社会公共卫生的监管。依法严厉打击各种危害人民群众身体健康和生命安全的违法行为完善医疗保障监管。加强对医疗保险经办、基金管理和使用等环节的监管,建立医疗保险基金有效使用和风险防范机制。强化医疗保障对医疗服务的监控作用,完善支付制度,积极探索实行按人头付费、按病种付费、总额预付等方式,建立激励与惩戒并重的有效约束机制。加强商业健康保险监管,促进规范发展。加强药品监管。强化政府监管责任,完善体系建设,严格药品生产、流通、价格、广告和使用的监管。落实药品生产管理规范,加强对高风险品种生产的监管。严格实施药品经营管理规范,探索建立药品经营许可分类、分级的管理模式,加大重点品种的监督抽验力度。加强政府对药品价格的监管,有效抑制虚高定价。规范药品临床使用,发挥执业药师指导合理用药与药品质量管理方面的作用。建立信息公开制度。鼓励行业协会等社会组织、个人对政府部门、医药机构和相关体系的运行绩效进行独立评价和监督。加强行业自律。
  
(十三)建立可持续发展的医药卫生科技创新机制和人才保障机制。立足卫生事业发展,服务人民群众健康,逐步建立层次完整、结构合理、重点突出、可持续的科技创新机制和人才保障机制。推进医药科技进步。把医药卫生科技创新作为国家科技发展的重点,以防病治病为中心,努力攻克医药科技难关,为人民群众健康提供技术保障。遵循自主创新、重点跨越、协调发展、引领未来的方针,深化医药卫生科技体制和机构改革,整合优势医学科研资源,加快实施医药科技重大专项,加强对重大疾病防治技术和新药研制关键技术等的研究,在医学基础和应用研究、高技术研究、中医和中西医结合研究等方面力求新的突破。针对人民群众的医疗卫生需求,加强医学科研,开发生产适合我国国情的医疗器械。广泛开展国际卫生科技合作交流。大力推广适宜技术,全面推进医药卫生科技进步。加强医药卫生人才队伍建设。制订和实施人才队伍建设规划,重点加强公共卫生、农村卫生、城市社区卫生专业技术人员和护理人员的培养培训。制定优惠政策,鼓励优秀卫生人才到农村、城市社区和中西部地区服务。对长期在城乡基层工作的卫生技术人员在职称晋升、业务培训、待遇政策等方面给予适当倾斜。完善全科医师任职资格制度,健全农村和城市社区卫生人员在岗培训制度,鼓励参加学历教育,促进乡村医生执业规范化,尽快实现基层医疗卫生机构都有合格的全科医生。加强高层次科研、医疗、卫生管理等人才队伍建设。培育壮大中医药人才队伍。稳步推动医务人员的合理流动,促进不同医疗机构之间人才的纵向和横向交流,研究探索注册医师多点执业。逐步规范医院管理者的任职条件,逐步形成一支职业化、专业化的医疗机构管理队伍。调整高等医学教育结构和规模。加强全科医学教育。完善标准化、规范化的临床医学教育,提高医学教育质量。加大医学教育投入,大力发展面向农村的高等医学本专科教育,采取定向免费培养等多种方式,为贫困地区农村培养实用的卫生人才,造就大批扎根农村、服务农民的合格医生。加强医德医风建设。重视医务人员人文素养培养和职业素质教育,大力弘扬救死扶伤精神。优化医务人员执业环境。在全社会形成尊重医学科学、尊重医疗卫生工作者的良好风气,努力构建健康和谐的医患关系。
  
(十四)建立实用共享的医药卫生信息系统。以推进公共卫生、医疗、医保、药品、财务监管信息化建设为着力点,加快信息标准化和公共服务信息平台建设,逐步建立统一高效、资源整合、互联互通、信息共享、透明公开、使用便捷、实时监管的医药卫生信息系统。加快医疗卫生信息系统建设。完善以疾病控制网络为主体的公共卫生信息系统,提高预测预警和分析报告能力。以建立居民健康档案为重点,构建乡村和社区卫生信息网络平台。以医院管理和电子病历为重点,推进医院信息化建设。利用网络信息技术,促进城市医院与社区卫生服务机构的合作,积极发展面向农村及边远地区的远程医疗。建立和完善医疗保障信息系统。加快基金管理、费用结算与控制、医疗行为管理与监督、参保单位和个人管理服务等具有复合功能的医疗保障信息系统建设。加强城镇职工、居民基本医疗保险和新型农村合作医疗信息系统建设,实现与医疗机构信息系统的对接,积极推广”一卡通”等办法,方便参保(合)人员就医,增加医疗服务的透明度。建立和完善国家、省、市三级药品监管、药品检验检测、药品不良反应监测信息网络,加强对药品研制、生产、流通、使用全过程关键环节的监控。
  
(十五)建立健全医药卫生法律制度。进一步加强医药卫生立法工作,逐步建立健全与基本医疗卫生制度相适应、比较完整的卫生法律制度。完善卫生法律法规。加快推进基本医疗卫生立法工作,明确政府、社会和居民在促进健康方面的权利和义务,保障人人享有基本医疗卫生服务。建立健全卫生标准体系,做好相关法律法规的衔接与协调。加快中医药立法工作。推进依法行政。严格执法,规范执法,切实提高各级政府运用法律手段发展和管理医药卫生事业的能力。加强医药卫生普法工作,提高全社会法律意识和法制观念,努力创造有利于人民群众身体健康的法制环境。五、着力抓好五方面重点工作,力争近期取得明显成效深化医药卫生体制改革要立足当前,从着力解决人民群众反映强烈的”看病难、看病贵”问题入手,让老百姓得到实惠,让医务人员受到鼓舞,让监管人员易于掌握。到 2010年,在全国初步建立基本医疗卫生制度框架。(十六)加快推进基本医疗保障制度建设。基本医疗保障制度全面覆盖城乡居民,城镇职工基本医疗保险、城镇居民基本医疗保险和新型农村合作医疗参保(合)率达到90%以上。促进各项基本医疗保障制度协调和衔接。完善医疗保障管理体制机制,逐步提高筹资和保障水平。进一步健全城乡医疗救助制度,明显减轻城乡居民个人医药费用负担。
  
(十七)初步建立国家基本药物制度。建立比较完整的基本药物遴选、生产供应、使用和医疗保险报销制度等体系,保证群众基本用药的可及性、安全性和有效性。规范基本药物的生产和配送,基层医疗卫生机构基本药物直接配送覆盖面力争达到80 %。合理确定基本药物的价格,完善基本药物的医保报销政策,提高合理用药水平,减轻群众基本用药费 用负担。
  
(十八)健全基层医疗卫生服务体系。加快农村乡镇卫生院、村卫生室和城市社区卫生服务机构建设,实现基层医疗卫生服务网络的全面覆盖,加强基层医疗卫生人才队伍建设,特别是全科医生培养培训,着力提高基层医疗卫生机构服务水平和质量,农村居民小病不出乡,城市居民享有便捷有效的社区卫生服务。转变基层医疗卫生机构运行机制和服务模式,完善投入机制,逐步建立分级诊疗和双向转诊制度,城乡居民基本医疗卫生服务费用负担减轻,利用基层医疗卫生服务量明显增加。
  
(十九)促进基本公共卫生服务逐步均等化。健全城乡公共卫生服务体系,逐步扩大国家公共卫生服务项目范围,向城乡居民提供疾病防控、计划免疫、妇幼保健、健康教育等基本公共卫生服务。实施国家重大公共卫生专项,有效预防控制重大疾病。进一步提高突发重大公共卫生事件处置能力。逐步缩小城乡居民基本公共卫生服务差距,提高全民健康水平。完善公共卫生服务经费保障机制,加强绩效考核,提高服务效率和质量。
  
(二十)推进公立医院改革试点。探索建立比较规范的公立医院管理体制和运行机制,采取有效方式改革以药补医机制,加大政府投入,规范收支管理,使药品、检查收入比重明显下降。改进内部管理,优化服务流程,规范诊疗行为,明显缩短病人等候时间,实现检查结果互认。六、积极稳妥推进医药卫生体制改革(二十一)切实加强领导。各级政府要充分认识深化医药卫生体制改革的重大意义,切实加强组织领导,把解决群众看病就医问题作为改善民生的重点摆上重要议事日程,落实政府的公共医疗卫生责任。国务院成立深化医药卫生体制改革领导小组,统筹组织实施深化医药卫生体制改革。国务院有关部门要认真履行职责,密切配合,形成合力。地方政府要按照本指导意见的要求,结合实际情况,因地制宜地制订具体实施方案和有效措施,精心组织,有序推进,确保改革成果惠及全体人民群众。
  
(二十二)突出重点,分步实施。建立覆盖城乡居民的基本医疗卫生制度是一项长期任务。国务院有关部门要按照本指导意见确定的基本方向和框架体系,抓紧制订相关配套文件,进一步深化、细化和实化政策措施,并做好各项制度、政策之间的配套和衔接,协调推进各项改革。近几年要重点抓好推进基本医疗保障制度建设、建立国家基本药物制度、健全基层医疗卫生服务体系、促进基本公共卫生服务均等化和推进公立医院改革试点等工作。
  
(二十三)组织开展试点工作。医药卫生改革涉及面广、情况复杂,对一些难点问题要先行试点,取得经验后逐步推广。近期要力争在探索公立医院管办分开、改革以药补医、规范运行机制和卫生投入机制等方面取得突破。国务院深化医药卫生体制改革领导小组负责统筹协调、指导各地试点工作,在全国选择部分地方或单位开展试点。中央负责制定试点原则和政策框架,地方负责制定具体试点实施方案并组织实施。鼓励地方继续探索创新,结合当地实际开展多种形式的试点。
  
(二十四)做好舆论宣传工作。医药体制改革直接关系广大群众的切身利益,是一项重大的民生工程,需要社会各界和广大群众的理解、支持和参与。要坚持正确的舆论导向,加强对深化医药卫生体制改革的重大意义、指导思想、基本原则和主要政策的宣传,总结推广好的试点经验,使这项惠及广大人民群众的重大改革深入人心,为深化改革营造良好的舆论环境。
English version:
17 in accordance with the spirit of party, for the establishment of Chinese medical and health system characteristics, the progressive realization of access to basic medical and health services, improve the level of health, are the following comments on the proposed reform.
I fully understand the medical and health system reform to deepen the importance and urgency and difficulty of health is the basis of all-round development of people.
The cause of the relationship between the medical and health well-being of millions of households, is a major livelihood issues. Deepening of the medical and health system reform, speed up the development of medicine and public health to meet the people’s growing demand for medical and health, and continuously improve the quality of people’s health, is to implement the scientific concept of development and the promotion of economic and social development of comprehensive, coordinated and sustainable natural requirement safeguard social fairness and justice in an important measure to improve people’s quality of life is an important symbol of a well-off society and building a harmonious socialist society, a major task.
Since the founding of new China, especially since the reform and opening, China’s medical and health has made significant achievements, covering urban and rural areas of the medical and health service system has basically taken shape, has continuously increased its ability for Disease Control and Prevention, health insurance coverage of the population gradually expanded rapidly rising level of health science and technology , the level of people’s health improved, the residents of developing countries mainly in the forefront of health indicators. In particular the fight against “SARS” has been a great victory was won, at all levels of government to increase investment in public health, rural and urban health accelerate the development of community health, new-type rural cooperative medical care and basic medical insurance for urban residents achieve a breakthrough medicine for deepening Health system reform has laid a good foundation.
At the same time, it should be noted that the cause of China’s current level of development of medicine and public health coordinated economic and social development with the requirements and not meet the health needs of the people are still quite prominent contradictions. Urban and regional imbalances in the development of medical and health, unreasonable allocation of resources, public health and rural, community medical and health work is relatively weak, health care systems, pharmaceutical production and circulation order of non-standardized, hospital management systems and operational mechanisms are imperfect, inadequate investment in government health, medical costs rose too fast, strong people and the masses. From now to 2020, is building a moderately prosperous society in our country critical period, the medical and health work tasks shoulders. With the economic development and people’s living standards, the masses to improve medical and health services will have higher requirements. Industrialization, urbanization, population aging, disease and ecological changes such as climate change, both the medical and health work a series of new challenges.
Deepening of the medical and health system, is to accelerate the development of medicine and public health strategic choice is to achieve the outcome of the reform and development of people to share an important way, is the broad masses of the people’s urgent hope. Chinese medicine is a broad, difficult and social systems engineering. China’s population and a low level of per capita income in urban and rural areas, regional disparities, and long-term in the primary stage of socialism’s basic national conditions, decided to deepen the medical and health system is a very complicated task, is a gradual process, the need for a clear direction and framework on the basis of hard work over a long period of exploration and perseverance in order to gradually establish the conditions of our country’s medical and health system.
Second, the guiding ideology of the reform of Chinese medicine, the basic principles and overall objectives
(A) the guiding ideology. The guiding ideology of the reform of Chinese medicine are: take Deng Xiaoping Theory and “Three Represents” as guidance, in-depth implementation of the scientific development concept, from China’s national conditions, benefit from international experience, focus on the realization of the right to basic medical and health services goals, and make efforts to resolve the masses of the people most concerned about, the most direct and practical interest. Adhere to public health of the public good nature, persist in focusing on prevention in order to focus on rural areas, both Chinese and Western medicine approach, the implementation of the conduct of public affairs separate, the management do separate, medicine separate, for-profit and non-profit separate from the Government to strengthen the responsibility and input, improve the national health policies, a sound system, and strengthen supervision and management, innovation and institutional mechanisms to encourage community participation, construction of urban and rural residents covered by basic medical and health system, and continuously improve the level of national health, promote social harmony.
(B) basic principles. Pharmaceutical reform should follow the following basic principles: people-oriented, to give top priority to safeguard the rights and interests of the people’s health. Adhere to the cause of the medical and health services for the purpose of the health of the people in order to protect the health of the people as the center and access to basic medical and health services as the fundamental starting point and final goal of the reform program from the design, the establishment of the health system to the service system must follow the public principle, reflect the strong focus on solving the outstanding problems, and strive to achieve all the people sick. Adhere to conditions based on the establishment of Chinese medical and health system characteristics. From China’s basic national conditions and seeking truth from facts summed up the cause of the medical and health reform and development of practical experience, an accurate grasp of the development of medicine and public health laws and the principal contradiction; adhere to the basic level of health services and economic and social development in harmony with the masses of the people to bear ability to adapt; give full play to the role of Chinese medicine; adhere to local conditions, direct classification, and to play a local initiative to explore the establishment of basic health care in line with the national health system. Adhere to fair and efficient unified, government-led market mechanism to play a role with the combination. Adhere to government-led, and strengthen the Government in the basic medical and health system the responsibility of the Government to strengthen the system, planning, financing, services, supervision responsibilities, and safeguard public health of the public welfare, and promote fairness and justice; At the same time, market-oriented mechanism role in promoting the formation of orderly competition and improve efficiency of health care and service levels, quality, meet the people’s multi-level, a variety of medical and health needs. Insist on integrated, to improve the system and resolve the current problems together. From the overall situation, taking into account the supply side and demand-side, such as the interests of all parties focus on prevention, treatment, rehabilitation of the combination of the three, the correct procedures for dealing with government, health agencies, pharmaceutical companies, medical personnel and the relationship between the masses of the people. Both long-term, innovative institutional mechanisms, but also focus on the current situation, and make efforts to resolve the medical and health problems that exist; not only focus on the overall design, a clear direction of the overall reform objectives and the basic framework, but also focused, step-by-step implementation, actively and steadily promote the reform.
(C) the overall objective. The overall objective of the reform of Chinese medicine are: the establishment of urban and rural residents covered by basic medical and health system for the masses to provide a safe, effective, convenient and inexpensive medical and health services. By 2020, urban and rural residents covered by basic medical and health system and the basic set up. Established a relatively complete system of public health services and medical service system, a relatively sound medical security system, the availability of drugs in a fairly standard security system, more scientific institutions of medical and health management system and operational mechanism, the formation of multi-run medical pattern for all basic medical and health services, the basic masses of the people to adapt to multi-level medical and health needs, the level of the people to further improve the health of the masses. Third, the four systems to improve medical and health, the establishment of urban and rural residents covered by basic medical and health system and the establishment of urban and rural residents covered by public health service system, the health care system, medical security system, security system, the availability of drugs in four-in-one system of basic medical and health , the four systems complement each other, supporting the construction of harmonious development.
(D) to strengthen public health services system. Establish and improve disease prevention and control, health education, maternal and child health, mental health, emergency medical treatment, blood collection, health surveillance and family planning service network, such as public health professionals and improve medical and health services to the grass-roots web-based health care system of public health services, the establishment of a clear division of labor, information exchange, resource sharing, coordination of interaction between the public health service system, improve public health services and the disposal of public health emergency response capacity, and promote urban and rural residents to enjoy a gradual equalization of basic public health services . To determine the scope of public health services. Clear national public health services, increasing service content, service and detailed assessment criteria. According to the local economy to encourage the local government level and a prominent public health issue, in the central provisions of services based on the content of public health services. Improve the public health service system. Further clarify the functions of public health service system, objectives and tasks, optimize the allocation of personnel and equipment to explore the integration of public health resources in an effective form of service. Improve disease prevention and control system and a major public health emergency response mechanism to strengthen a serious threat to people’s health infectious diseases, endemic, occupational and chronic diseases such as the prevention and control and monitoring. Strengthen the urban and rural first-aid system. Strengthen health promotion and education. Medical and health institutions and agencies, schools, communities, enterprises need to vigorously carry out health education, advocate a healthy and civilized way of life, the use of radio, television, networks, newspapers and magazines and other media to enhance the health, medical and health knowledge dissemination, the promotion of public rational nutrition to improve the health of the masses and self-care ability. Patriotic public health campaign carried out in depth. Rural sanitation and environmental management into a new socialist countryside construction planning, and promote the health of cities and villages of civilization-building, continuous improvement of urban and rural residents to live, work and other aspects of environmental health. Strengthening health supervision services. Promoting environmental health, food hygiene, occupational health, school health and health of migrant workers.
(E) further improve the medical service system. Adhere to non-profit medical institutions as the main body, for-profit medical institutions added that the public sector-led, non-public medical institutions to do the common development of medical principles, the construction of a rational structure, a clear division of labor, combined with prevention and control, technology suitable for operation in an orderly manner, including coverage of urban and rural primary health care and health services, including network and various types of hospital medical service system. Vigorously develop the rural health service system. Sound in order to speed up the establishment of county-level hospitals as a leader, as the backbone of township hospitals and village clinics in rural areas based on the three-tier network of health services. County-level hospitals in the region as a county health center, is mainly responsible for hospital-based basic medical services and emergency treatment of critically ill emergency patients, and to bear on the operations of rural health technical guidance and training of rural health personnel training; responsible for township hospitals provide public health services and the common, frequently-occurring disease, such as multi-service clinics and village health commitment to business management and technical guidance, etc.; village administrative villages and the general public health services for diagnosis and treatment of diseases and so on. Conditions in rural villages can be integrated management. Speed up the implementation of rural health service system planning and development, actively promote the rural health infrastructure and capacity-building, focus on good government and county-level hospitals in each town and township hospitals in a well, a variety of ways to support the construction of village health vigorously to improve rural medical and health conditions, improve medical and health service quality. Improve community health service based on a new type of urban medical service system. To develop community health services, in order to accelerate the construction of community health service centers as the mainstay of urban community health service network, and improve community health services, in order to safeguard the health of community residents as the center, to provide for Disease Control and Prevention and other public health services and general diseases, frequently-occurring disease, the primary treatment of chronic diseases. Changes in community health services, insist on active service, door-to-door service, and gradually take on the health of residents “gatekeeper” role. Improve the types of functions and responsibilities of the hospital. Optimize the layout and structure of the hospital and give full play to the city hospital in the acute and severe disease and diagnosis and treatment of illnesses, medical education and scientific research, guidance and training of health personnel, such as the grassroots backbone of the role of context. University Hospital of conditional planning requirements in accordance with the regional health through care, and reorganization of health care resources to promote the rational flow. The establishment of urban hospitals and community health services division of the coordination mechanism. City Hospital, through technical support, training of personnel, promote the sustainable development of community health. At the same time, to improve the service capabilities and lower fees, raise the proportion of such claims comprehensive measures to guide the general clinic sink to the grassroots level, the progressive realization of the first community clinic, and two-way classification of medical referral. Integration of urban health resources, make full use of existing urban primary and secondary hospitals and medical institutions of state-owned enterprises, such as primary health care resources, the development and improvement of community health service network. Give full play to include ethnic Chinese medicine including Chinese medicine in disease prevention and control, responding to public health emergencies, the role of medical services. Strengthen the research base of Chinese medicine and Chinese medicine hospital clinical building, organizations of Chinese medicine to combat diseases of the joint research, in medical and health institutions to promote appropriate technology in medicine. Create a favorable policy environment to support the development of Chinese medicine, Chinese medicine to promote the inheritance and innovation. Support the establishment of urban hospitals in rural medical and health care system. Developed regions to strengthen the poverty-stricken areas to support regional development and minority health care. Cities with large hospitals in poor areas and minority regions of the county-level hospitals to establish long-term stability of the system of support and cooperation to take clinical services, personnel training, technical guidance, equipment support, etc., to help them improve the health level and service capabilities.
(Vi) accelerate the construction of the medical security system. In order to speed up the establishment and improvement of basic medical insurance as the main body, and other forms of medical insurance and supplementary health insurance to supplement the business, covering both urban and rural residents of multi-level medical security system. The establishment of urban and rural residents covered by basic medical insurance system. Basic medical insurance, basic medical insurance for urban residents, the new rural cooperative medical care and medical assistance in urban and rural areas together constitute the basic medical security system, urban employment, respectively, covering population, the urban employed population, the rural population and vulnerable groups in urban and rural areas. Insist on wide coverage, basic security, and sustainable principles, focus on the protection of serious illness from the start, and gradually extended to the clinic for minor illnesses and improve the level of protection. The establishment of a national, unit, family and personal responsibility clear, reasonable sharing of multi-channel financing mechanisms, to achieve social互助共济. With the economic and social development, and gradually increase the level of funding and co-ordination level, narrowing the gap between the level of protection, and ultimately the basic framework of a unified system. Further improve the basic medical insurance system, to speed up the coverage of the working population, focusing on the closure of bankrupt state-owned enterprises, enterprises and other employees and retirees, as well as mixed ownership, non-public economic organizations and flexibility of employees employed medical insurance issues; speed up the town residents in the basic medical insurance pilot project, to fully open in 2009, attention to the elderly and children to resolve the basic medical insurance issues; the full implementation of new rural cooperative medical system, and gradually increase the level of government subsidy, the farmers pay the appropriate increase and improve support capabilities. Improve the urban and rural medical assistance system. Of difficulties and can not afford the insurance costs of health care subsidies, health insurance and build a strong bottom line. Conditional region to take a variety of ways to actively explore the establishment of urban-rural integration of basic medical insurance management system. To encourage trade unions and other social organizations to carry out the activities of various forms of medical mutual aid. Encourage and guide various types of non-profit charitable organizations, the development of social medical assistance. Do a good job in basic medical insurance system for urban residents in the basic medical insurance system, the new rural cooperative medical care system and between urban and rural medical assistance system for the convergence of migrant workers to properly resolve the issue of the basic medical insurance. Signed labor contracts with enterprises to establish a stable labor relations of migrant workers, according to state clearly the responsibility of employers to pay its workers in towns and cities included in the basic medical insurance system; other according to the actual situation of migrant workers, to participate in the location of residence or the new rural cooperative medical workers the location of the basic medical insurance for urban residents. Positive relationship between the health of migrant workers do a good job in follow-up, remote medical treatment and the cost of clearing and settlement services, such as policy convergence. Active development of commercial health insurance. To encourage the development of commercial insurance agencies to adapt to the different needs of the health insurance products, claims to simplify procedures for the masses, to meet the diverse health needs. Encourage businesses and individuals through participation in various forms of commercial insurance and supplementary medical insurance protection to meet the basic needs outside. Continue to explore commercial insurance sector to participate in the new rural cooperative medical care, such as the way managers manage.
(Vii) establish and improve the drug supply security system. To the establishment of a national system based on essential drugs, to nurture an internationally competitive pharmaceutical industry, pharmaceutical production and circulation enterprises to increase concentration, regulate the order of pharmaceutical production and circulation, improve the pricing mechanism for drugs, to strengthen government regulation as the main content, building standardized, intensive of the drug supply support system, and constantly improve the system of licensed pharmacist to protect the people’s security agents. The establishment of a national system of essential drugs. The central government to develop and publish uniform national essential medicines list, in accordance with the control necessary, safe, effective, affordable, easy to use, the principles of both Chinese and Western medicines, combined with the characteristics of China’s drug use, in the light of international experience and reasonable to determine the basic varieties and quantities of drugs. The establishment of the production of essential drugs supply system, under the government’s macro-control and give full play to the role of market mechanism, the implementation of essential drugs by the state fixed-point production or concentration of the tender procurement, direct distribution, to reduce intermediate links, at a reasonable profit to determine the level of production based on the unified the development of the retail price to ensure that the production and supply of essential drugs, basic drugs to protect the masses. Regulate the use of essential drugs, basic drugs used to formulate norms and guidelines for clinical application. Urban community health service centers (stations), township hospitals, village clinics and other primary care health institutions should all use of essential drugs, other types of medical institutions will have to essential drugs as the preferred use of the drug and to determine the ratio. Essential drugs into the basic medical insurance system directory of drug reimbursement, reimbursement was significantly higher than the proportion of non-essential drugs regulate the production and circulation of drugs. Pharmaceutical industry to improve the development of the industry development policies and planning, strict market access, strict drug registration approval, standardize and consolidate the strong production and circulation order, promote the optimization and upgrading of the pharmaceutical industry and technological progress, the development of modern pharmaceutical logistics and chain operation, the promotion of pharmaceutical production, circulation enterprise integration. The establishment of wide-coverage system, convenience Huinong rural medicine supply network and monitoring network. To support the small amount of the special agents, the production of first-aid medication. Improve the reserve system drugs. Standardize drug procurement, purchase and sale of pharmaceuticals firm governance of commercial bribery. Strengthen the monitoring of adverse drug reactions, the establishment of early warning mechanisms and drug safety mechanisms to deal with emergencies. Fourth, improving the institutional mechanism to ensure effective regulation of the medical and health system to improve the functioning of the medical and health management, operation, investment, pricing, monitoring systems and mechanisms to strengthen science, technology and human resources, information, and the legal system to protect the norms of the medical and health system functioning effectively.
(Viii) the establishment of a coordinated and integrated medical and health management system. Separately in accordance with the conduct of public affairs, Office of separate tubes, territoriality and the principle of management of the entire industry, to determine a reasonable level of government between different government agencies and between the medical and health terms of reference, the formation of clearly defined functions, positioning a clear, comprehensive coordination, powers and responsibilities of a unified management system. The implementation of territorial management and the entire industry. All medical and health institutions, regardless of ownership, investment in the main, affiliation and the nature of the business by the seat of health authorities to implement unified access the supervision unification. Central, provincial commitment to set up a small amount of medical research and teaching functions of the medical center or regional medical centers, national or regional commitment to the diagnosis and treatment of illnesses and other health care specialist hospitals; counties (cities, districts) is mainly responsible for organizing at the county level hospitals and rural health and community health agencies; the rest of the public hospital districts from the city responsible for. Strengthen the regional health planning. Provincial People’s Government to develop standards for health resource allocation, organizational development of regional health planning and health care institutions planning, specifically the number of medical institutions, scale, layout and functionality. Science and the development of township hospitals (village), community health service centers (stations) and other grass-roots health organizations and all levels of hospital construction and equipment standards. Take full advantage of and optimize the allocation of existing health care resources, adjust and optimize the structure and layout, do not comply with the planning requirements of the medical institutions should be gradually integrated, strictly control the configuration of major medical equipment, to encourage the build-sharing and improve the efficiency of health care resource utilization. Additional health resources must comply with the regional health planning, focusing on rural and community health such as weak links. The strengthening of regional health planning and urban development planning, land use planning, such as the convergence. The establishment of regional health planning and resource allocation mechanism for monitoring and evaluation. Promote the reform of the management system of public hospitals. From public hospitals in favor of strengthening the effective regulation of public welfare and the government must actively explore the conduct of public affairs separate, separate from the tube to do a variety of forms. To further transform government functions, public health administration is mainly responsible for health development planning, access qualifications, standards, service industry management functions such as regulation, other relevant departments to carry out their respective functions in accordance with the management and delivery of services. Implementation of an independent legal person status in public hospitals. Further improve the basic medical insurance management system. Central development of the basic medical insurance system and policy framework, local government is responsible for organizing the implementation of management, to create conditions to gradually improve the level of co-ordination. Effective integration of the basic medical insurance resources, the progressive realization of the basic medical insurance in urban and rural areas of the unified administration.
(Ix) the establishment of a standardized and efficient medical and health agencies operating mechanism. In order to protect the public nature of public medical and health institutions at the core, and gradually establish a standardized, scientific, efficient and orderly operation of mechanisms for the medical and health institutions. All public health agencies be included in the budget revenue and expenditure management. Responsibilities in accordance with the tasks identified by the Government reasonable staffing, wage levels and funding criteria, clear job responsibilities of all categories of personnel, strict personnel access, strengthen the performance assessment, the establishment can be of use to increase work efficiency and service quality . Changes in primary health care health care institutions operating mechanism. Part of the government’s urban community health service centers (stations) and township hospitals and other primary care health institutions, it is necessary to strictly define the services, clearly require the use of appropriate technology, appropriate personnel, appropriate equipment and essential drugs, in order to provide low-cost services to the masses, the nature of the maintenance of public welfare. The authorized staffing level to strictly implement employment system, the establishment can be up and motivate effective human resources management system. To clear the scope and standards of income and expenditure, the implementation of approved mission, the approved revenue and expenditure, performance evaluation of the financial management of grants, and to explore the implementation of separation of revenue and expenditure, public health and health care advances, such as the total amount of funds a wide range of effective management approach, strict budget management, improve capital efficiency. Addition to the reform of drug policy, the implementation of pharmaceutical sales slip zero. Strengthen and improve the internal management, the establishment of the quality of service as the core in order to position responsibilities and performance-based evaluation and incentive systems, and form a long-term protection of fair and efficient mechanism for the establishment of a standardized operational mechanism of public hospitals. Public hospitals to follow the nature of public goods and social benefits of the principle of patient-centered, and optimize service processes, and standardize inspection and medical drugs, deepening the reform of operational mechanism. The establishment and improvement of hospital corporate governance structure, clear responsibilities of owners and managers the right to form a decision-making, implementation, monitoring of checks and balances, have the responsibility, there are incentives, there are bound, competitive and dynamic mechanism. The implementation of separate management of revenue and expenditure of Chinese medicine, and explore effective ways to gradually reform the mechanism of drug treatment completed. Difference between the purchase and sale of drugs through the introduction of fare increases and service charges are a variety of Pharmaceutical and progressive reform or abolish the policy of drug addition and at the same time to take appropriate adjustment of prices of medical services, increasing government investment, the reform of payment and other measures to improve the compensation mechanisms in public hospitals. Further improve the financial and accounting management system, strict budget management, strengthen financial supervision and operational oversight. Place in conjunction with local realities, and the hospital conditions, “the approved revenue and expenditure in order to support arrived, turned over the over-enrollment, the difference between grants, clear rewards and punishments,” such as management of the pilot. The personnel system reform and improve the allocation of incentive mechanism, the implementation of the employment system and post management system, the total wage bill in the strict management, the implementation of the quality of services and jobs to the workload of an integrated performance-based job performance evaluation and wage system, to effectively mobilize the enthusiasm of the medical staff. Sound health care insurance agencies operating mechanism. Improve the internal governance structure, establish a rational mechanism and distribution system, improve the incentive and restraint mechanisms to improve the management capacity of health care insurance and management efficiency.
(J) the establishment of government-led mechanism for multi-health investment. Clear the Government, the community input and personal responsibility, the establishment of the Government in the provision of public health and basic medical services in the leading position. Public health services, mainly through government funding, to provide equalization of urban and rural residents. Basic medical services are provided by the Government, social and personal sharing of the cost of the three. Special need of medical services paid by individuals directly or through commercial health insurance. The establishment and improvement of government health input mechanism. Central and local governments should increase input in health, taking into account the supply side and demand-side. Gradually increase in government health costs accounted for the proportion of total health, so that the residents basic health care to reduce costs significantly; government health input to the growth rate of recurrent expenditure is higher than the growth rate of government recurrent health into account the proportion of financial expenditure gradually be increased. New focus on government investment to support public health, rural health, urban community health and basic medical care. In accordance with the principle of reasonable classification division of the burden of the central and local levels of government responsibility for health investment. The primary responsibility of local governments, the central government mainly on the national immunization plan, cross-regional prevention and control of major infectious diseases, such as public health, urban and rural residents, the basic medical insurance as well as the public health, such as institution-building grant. Increase the central, provincial financial difficulties in areas of special transfer payments. Improve the Government’s Public Health of the input mechanism. Professional staff of public health services funding, development and construction and operational funding arrangements by the Government in full, in accordance with the provisions of the Financial services income paid into the account or budget management. Gradually increase the per capita public health funding, a sound mechanism to ensure funding for public health services. Improve the Government’s urban and rural primary care health facilities into the mechanism. Organized by the Government responsible for its township hospitals, urban community health service centers (stations) approved by the state capital, equipment purchase, staff and their commitment to funding the operating costs of public health services to normal operation. Including all social forces organized township hospitals and urban community health service institutions, can be taken around the purchase of approved services, government grants. Support the construction of village clinics, village doctors to assume the tasks of public health service grants given reasonable. Government subsidies to implement the policy in public hospitals. Gradually increase the government investment, mainly for infrastructure and equipment to support the development of key disciplines, in line with the state retirees cost and loss of subsidies and so on and so on to assume the task of public health services to give special subsidies to form a reasonable specification The mechanism of government investment in public hospitals. Of Chinese medicine hospital, hospital for infectious diseases, psychiatric hospitals, maternal and child health care such as hospital and children’s hospital in favor of policy input. Public hospitals to strictly control the scale of construction, standards and lending behavior. Government to improve protection of the basic medical input mechanism. Government to provide the necessary financial support for the new rural cooperative medical care, basic medical insurance for urban residents, the basic medical insurance for urban workers and urban and rural medical assistance system for the establishment and improvement. To ensure that the relevant funding agencies to normal. Encourage and guide the development of social capital and health care. Actively promote the development of non-public medical institutions, the formation of investment diversification, diversification of investment to do the medical system. Pay close attention to the design and development of relevant policies and regulations, social norms do medical institutions, including foreign operators access to medical institutions, improve the management of fair and equitable trade policies. To encourage the establishment of social funds in accordance with the law of non-profit medical institutions. Countries to develop the public hospitals of the guidance system, and actively guide the community to participate in funding to a variety of ways, including the running of hospitals by state-owned enterprises, including some restructuring and reorganizing public hospitals. Steady progress in restructuring public hospitals in the pilot, appropriately reduce the proportion of public medical institutions, the formation of public hospitals and non-public hospitals, mutual promotion and common development. Qualified personnel to support the business in accordance with the law to facilitate the masses of medical treatment. Classification of medical institutions to improve management policies and preferential taxation policies.社会办医in accordance with the law to strengthen supervision. Vigorously develop charity. The development of relevant policies to encourage the social forces to set up a charitable medical institutions, or to medical assistance, medical institutions, such as charitable donations.
(Xi) to establish scientific and reasonable pricing mechanism of Chinese medicine. To improve market regulation and the regulation of the combination of objective reflection of market demand and supply, changes in cost and production services, medical services and pharmaceutical pricing mechanism. Regulate the prices of medical services management. Non-profit medical institutions to provide basic medical services, the implementation of the Government指导价, and the remaining independent pricing by medical institutions. The central government responsible for medical services and project pricing policies, pricing principles and methods; provincial or municipal department in charge of prices in health, labor and social security department approved the guidance of the basic price of medical services. Prices of basic medical services in accordance with the deduction of the cost of the services of financial assistance to develop, reflecting the cost of medical services and technical labor value. Different levels of medical institutions and doctors to provide services to the different levels of pricing. Regulate fees and charges at public medical institutions and standards, according to research diseases such as reform of fees and charges. The establishment of medical examination and treatment equipment, monitoring equipment prices, service prices and services going to cost adjustment system regularly. Drug pricing mechanism reform. Reasonable adjustments to the scope of government pricing, drug pricing methods to improve the use of price leverage to encourage enterprises to independent innovation, promote the state’s basic drug production and use. New drugs and patent medicines for the progressive introduction of market economy of the former drug evaluation system. Generic drugs to market prices after the implementation of the system from low-priced, low-level redundant construction inhibition. The implementation of the mark in the drug package price. Strictly control the spread rate of drug circulation. Carried out for hospital differences in medicines increase sales, service fees charged Pharmaceutical pilot to guide rational drug use hospitals. Strengthening of medical supplies and plantations (referral) to the category of medical devices in circulation and use of part of the price control and management. Medicine price monitoring system and improve and standardize the pricing behavior enterprises. Actively explore the establishment of medical insurance agencies and medical institutions, pharmaceutical supplier negotiation mechanism to play a medical insurance for medical services and the cost of restricted drugs.
(Xii) the establishment of strict and effective supervision of the medical and health system. Improve the monitoring network, the strengthening of our supervisory responsibilities, regulatory innovation means to enhance the regulatory capacity in accordance with the law, the gradual establishment of the Government as the main body, the community to participate in a multi-institutional strengthening of the regulatory supervision of medical and health care. Improve the health supervision and law enforcement system, strengthening of institutional capacity-building health supervision. To strengthen medical and health services and quality control, good medical and health service standards and quality evaluation system, standardized management system and workflow, accelerate the formulation of unified norms disease clinics, medical and health services and improve quality monitoring network. Medical and health institutions to enhance access to and operation of the monitoring. Enhance the life of drinking water, occupational health, food safety, public health and other social regulation. Hazards in accordance with the law crack down on people’s health and improve the safety of health care regulatory law. Strengthening of medical insurance, fund management and supervision of the use of such links, the establishment of effective use of medical insurance funds and risk prevention mechanism. Strengthen the health care of the monitoring role of health care services, improve the payment system, and actively explore the implementation of a per capita payment, paid by the disease, such as the total amount paid in advance, the establishment of both incentive and an effective disciplinary mechanism. To strengthen the commercial health insurance regulation, to promote the development of norms. To strengthen the drug. Responsibility to strengthen government supervision and improve the system, strict pharmaceutical manufacturing, distribution, pricing, advertising and the use of supervision. The implementation of management standards in pharmaceutical production, enhance the production of high-risk species regulation. Strictly regulate the operation and management of the implementation of drugs to explore the establishment of pharmaceutical business license classification, hierarchical management style, greater focus on supervision and testing efforts varieties. Strengthen the Government’s regulation of drug prices, to effectively control the pricing High. Standardize the clinical use of drugs, to play a licensed pharmacist to guide rational drug use and drug quality management. The establishment of information disclosure system. To encourage trade associations and other social organizations, individuals to government departments, medical institutions and the operation of performance-related system to conduct an independent evaluation and oversight. To strengthen industry self-regulation.
(Xiii) Establishment of sustainable development in the medical and health personnel in scientific and technological innovation mechanism and protection mechanism. Based health development, health services to the masses, and gradually establish a level of integrity, well-structured, focused, and sustainable mechanism for scientific and technological innovation and personnel protection mechanism. To promote scientific and technological progress of Chinese medicine. The medical and health science and technology innovation as the focus of national science and technology development in order to prevent and cure diseases as the center, efforts to overcome the difficulties of Chinese medicine science and technology for people’s health to provide technical support. Adhere to independent innovation, focusing on cross-and coordinated development, to lead the policy of the future, and deepen the medical and health science and technology system and institutional reforms, integration advantages of medical research resources to speed up the implementation of major special medical technology to enhance disease prevention and control of major technology and new drugs such as the development of key technologies research, both basic and applied medical research and high-tech, traditional Chinese and western medicine and Chinese medicine research seeks to break new ground. For people’s health needs, to strengthen medical research, development and production of suitable medical equipment to China’s national conditions. Broad international cooperation and exchange of health science and technology. To promote appropriate technology, comprehensive medical and health to promote scientific and technological progress. Strengthen the building of the medical and health personnel. Personnel development and implementation of construction planning, focusing on strengthening the public health, rural health, urban community health professional and technical personnel training and training of nursing staff. The development of policies to encourage the outstanding health professionals to rural areas, urban communities and the central and western areas. For long-term grass-roots work in urban and rural areas of health promotion and technical personnel in the title, business training, treatment policies appropriate tilt. General practitioners improve the qualifications system, and perfect the rural and urban community health workers on-the-job training system to encourage participation in academic education, to promote the standardization of village doctors to practice as soon as possible to achieve primary health care health care institutions have a qualified general practitioner. Strengthen high-level scientific research, medical, health management personnel. Nurture strength of Chinese medicine personnel. Steadily promote the rational flow of medical personnel, and promote talent among the different medical institutions of the vertical and horizontal exchange of research physicians registered to practice more. Gradually standardize the conditions of the hospital managers, and gradually form a professional and specialized management team of medical institutions. Adjustment of higher medical education structure and size. Strengthening of medical education in general. Improve the standardization, the standardization of clinical education and improve the quality of medical education. Increase in medical education, vigorously develop the rural areas for the specialist of higher medical education, directed to take a variety of ways, such as free training for the poor rural areas of practical training of health personnel, a large number of roots in rural areas, services of qualified doctors farmers. To strengthen the construction of medical ethics. Emphasis on humanistic quality of medical staff training and professional quality education, vigorously carry forward the spirit lives. Optimization of medical practice environment. Formed in the whole society to respect medical science, respect for good health among workers, and strive to build a healthy and harmonious relationship between doctors and patients.
(Xiv) the establishment of sharing and practical medical and health information systems. To promote the public health, medical, health, medicine, construction and financial monitoring information for the focus to accelerate the standardization of information and public service information platform for building, and gradually establish a unified high-performance, resource integration, interoperability, information sharing, transparent and easy to use , real-time monitoring of the medical and health information systems. Speed up the construction of medical and health information systems. Improve disease control network as the main public health information systems, improve the forecast and analysis of early warning reporting capabilities. Files to create a focus on the health of residents, to build rural and community health information network platform. To hospital management and electronic medical records, focusing on pushing forward the construction of hospital information. The use of network information technology, promote the city’s hospitals and community health service agencies, and actively develop rural and remote areas of telemedicine. The establishment and improvement of health care information systems. Speed up the fund management, the cost of clearing and control, medical management and supervision, and insurance management services to units and individuals with complex functions, such as health care information system. Strengthen the urban workers, residents in the basic medical insurance and the new rural cooperative medical information system, medical institutions with the docking information system, and actively promoting the “One Card” and other ways to facilitate the insurance (co-) medical treatment and increase the transparency of medical services. The establishment and improvement of national, provincial and municipal regulation of the three drugs, drug test detection, monitoring of adverse drug reactions information network, strengthening of drug development, production, circulation, use the key to the whole process of monitoring.
(15) Establishing a sound legal system of medicine and public health. Legislation to further strengthen the medical and health work, and gradually establish and perfect the basic medical and health system to adapt to, relatively complete legal system health. Improve the health laws and regulations. Accelerate the basic medical and health legislation, specifically the Government, the community and residents in health promotion of the rights and obligations to protect access to basic medical and health services. Establish and improve standards of health, good laws and regulations related to convergence and coordination. Chinese medicine to speed up the legislative work. Promoting administration according to law. Strictly enforce the law and norms of law enforcement, governments at all levels to effectively improve the use of legal means to develop and manage the capacity of medical and health undertakings. To strengthen the work of the medical and health law popularization, to enhance the legal awareness of the whole society and the legal system, efforts to create conditions conducive to the health of the people of the legal environment. Fifth, efforts focus on five priorities, and strive to achieve marked results in the near future to deepen the medical and health system to focus on the current situation, from the efforts to resolve the masses of the people reflect a strong “hard to see a doctor, a doctor of your” problems, so that ordinary people benefit, so that medical personnel encouraged by regulators to allow easier. By 2010, the initial establishment of the national health system, the basic framework. (16) accelerating the construction of a basic medical insurance system. A basic medical insurance system covering both urban and rural residents a comprehensive, basic medical insurance, basic medical insurance for urban residents and the new rural cooperative medical insurance (combined) rate of 90%. The promotion of the basic medical insurance system of coordination and convergence. Management system to improve mechanisms for health care, and gradually increase the level of funding and security. Further improve the urban and rural medical assistance system, significantly reduce the cost of urban and rural residents the burden of personal medicine.
(Xvii) the initial establishment of a national system of essential drugs. To build a more complete selection of essential drugs, the production of the supply, use and health insurance reimbursement system, system to ensure that the masses of basic drugs and sex, the safety and efficacy. The basic norms of production and distribution of drugs, primary care health institutions direct distribution of essential drugs and strive to achieve coverage of 80%. Reasonable to determine the price of essential drugs, basic drugs to improve health insurance reimbursement policy, to raise the level of rational drug use, basic medication to alleviate the cost burden of the masses.
(Xviii) a sound system of primary health care and health services. Speed up the rural township hospitals, village and urban community health service institution-building, primary health care and health services to achieve comprehensive network coverage, enhance the provision of primary medical and health personnel, especially the training of general practitioners in training, focus on improving primary health care services to health institutions the level and quality of rural residents not minor illnesses township, city residents enjoy the convenient and effective community-based health services. Changes in primary health care health care institutions operating mechanisms and modes of service delivery, improve the investment mechanism, the gradual establishment of clinics and two-way hierarchical referral system, urban and rural residents, the cost of basic medical and health services and reducing the burden, the use of primary health care and health services increased significantly.
(19) basic public health services to promote the gradual equalization. A sound system of public health services in urban and rural areas and gradually expand the scope of national public health services to urban and rural residents for Disease Control and Prevention, immunization, maternal and child health, health education and other basic public health services. The implementation of major national public health specific and effective prevention and control of major diseases. Further improve the emergency disposal of a major public health capacity. Urban and rural residents to gradually narrow the gap between the basic public health services and raise the level of national health. Improve the mechanism to ensure funding for public health services, strengthening performance appraisal, improving service efficiency and quality.
(20) to promote reform of public hospitals. Explore the establishment of public hospitals in a fairly standard management system and operational mechanism, to take an effective way to reform in order to complement the medical mechanism of drugs, increased government investment, and standardize management of revenue and expenditure, so that drugs, check the proportion of income has declined markedly. To improve the internal management, and optimize service processes, and standardize medical act was significantly shorter waiting time for patients to achieve mutual recognition of test results. Sixth, actively and steadily push forward the medical and health system (21) effectively strengthen their leadership. Governments at all levels should fully understand the medical and health system reform to deepen the significance of, and strengthen management, to solve the problem of the masses of medical treatment focused on improving people’s livelihood as the top of the agenda of the Government’s public health responsibilities. The establishment of the deepening of the State Council Leading Group for the medical and health system, co-ordinating body to deepen the implementation of the medical and health system. State departments should earnestly perform their duties in close, to create synergy. Local governments in accordance with the requirements of this guidance in light of the actual situation, in line with local conditions to develop specific and effective measures to implement the program, carefully organized and in an orderly way to ensure that the results of the reform to benefit all the people.
(22) focused, step-by-step implementation. The establishment of urban and rural residents covered by basic medical and health system is a long-term task. Departments of the State Council in accordance with this guidance to determine the direction and framework of the basic system, pay close attention to the formulation of relevant supporting documents, further deepened, refined and practical policy measures, and do a good job in the system, policy convergence between the support and coordinate to promote reforms. In recent years to focus on promoting the basic medical security system, the establishment of a national essential drug system, a sound system of primary health care and health services, the promotion of basic public health services and promote equality of reform in public hospitals and so on.
(23) To organize the experimental work carried out. Chinese medicine covers a wide range of health reform, the situation is complex and difficult problems in a number of pilot projects to be achieved gradually extend the experience. The near future we will strive to explore in public hospitals in separate tubes do, reforms to complement the medical drugs, and regulate operating mechanism and input mechanism, such as health breakthrough. Deepening of the State Council Leading Group for the medical and health system is responsible for co-ordination, guidance throughout the pilot project, part of the country or select pilot units. Central is responsible for formulating the principles and policy framework for the pilot, local pilot responsible for the implementation of specific programs and organizations. Continue to explore ways to encourage local innovation, combined with various forms of local pilot.
(24) public opinion and propaganda work to do a good job. Medicine directly related to the reform of the vital interests of the masses is a major livelihood projects, the needs of the community and the general public understanding, support and participation. To insist on correct guidance of public opinion and strengthen the medical and health system reform to deepen the significance of the guiding ideology, basic principles and major policies of the publicity, the promotion of a good summary of the pilot experience, which will benefit the broad masses of the major reform of the people, in order to deepen the reform of public opinion to create a good environment.



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