| 摘要: | 在現代社會中，並不是每個人都能平等地享受到今天我們在健康上所見證的進步與成果，進而導致每個國家不可或缺的醫療保健服務成為一個可製造也同時可以消弭健康不平等的主要原因之一。醫療保健系統所包含的醫療服務提供、健康促進以及疾病防治足以使它成為一個重要的健康之社會決定因素。
本論文共涵蓋四項研究，以三大循序漸進之主題去研討於國家以及個人層面的相關議題：1)普及化的基層醫療保健；2)醫療保健與社會經濟不平等；及3)兒童早期的健康不平等。本研究主要將由政策角度切入，從全球到國內的觀點去試著尋求醫療資源的不均等分配而導致健康不平等之科學證據與其他相關因子，同時以其決定本論文架構。
第一項研究探討針對低收入和中等收入國家內的基層醫療保健覆蓋面擴大是否影響其國民之健康。嬰幼兒時期為全人發展中的重要時期，穩定與健康的初期發展可確保正常發育，但相反的，在這期間所受到的負面影響也可對一生健康造成無法彌補的缺陷。第二項研究想瞭解臺灣地區活胎且單胞胎之早產或低出生體重嬰兒的存活機率是否受父母親社會經濟地位、出生後之醫療保健使用與基層預防保健利用狀況存有相關性。第三項研究針對產出早產或低出生體重以及正常體重或滿週期嬰兒之母親進行探討，分析其妊娠期間所使用牙醫醫療照護之狀況是否影響分娩結果，而其家庭社經地位是否有作用修飾效果。第四項研究則是想瞭解臺灣現行的醫療制度下的肺癌患者延遲診斷狀況，並找出與它相關的因素。
整體而言，本論文發現人口群體間的健康與各醫療照護體系的設計、可使用醫療保健服務的種類、該服務的覆蓋面、其可近性與可用性以及人民就醫行為的差異有相當程度的關聯與影響。例如，窮人和受邊緣化族群在現行臺灣全民健康保險制度下，還是會因為地區分配的資源不均以及醫療費用部分負擔而無法受到適當的照顧，從而增加早產或低出生體重嬰兒死亡率的風險。此外，以一個固定經濟發展程度而言，人民的健康並不會因為醫療花費的多寡或來源而產生太大的改善，最重要的是我們是否能使基層醫療服務涵蓋到每個人。
本論文之結果雖然提供了可使用於評估人口健康的良好佐證，特別是針對特定人群如母親、早產或低出生體重新生兒與癌症患者，本論文所包含之研究設計也因為取得的資料特性而需做出多項假設，因而產生研究限制。本研究建議未來可進一步瞭解屬於上游的健康決定因素與健康不平等的關係。
Much of today’s health advances are not equally shared among populations. Health care plays a major role in generating and ameliorating inequalities in health. The service delivery, health promotion, disease prevention and public health together facilitate health care as a determinant of health.
This dissertation contains four studies and addresses three areas of concern regarding health at the population- and individual-levels: 1) universal coverage for primary health care, 2) health care and socioeconomic inequalities, and 3) inequalities in early child health. The studies seek to address health care issues from the policy perspective channeling down from global through to the domestic context, determining the structural arrangement for the dissertation.
The first study investigates the impact of coverage expansion of primary health care on the health of people in low- and middle-income countries. The second study explores the effect of parental socioeconomic status on prenatal care, health service utilization and survival of live-born, singleton preterm or low birth weight babies. The third study examines the influence of disease-specific dental service seeking behavior of mothers during pregnancy on preterm or low birth weight deliveries, and whether differential household income acts as a moderator in this association after implementation of the universal health care system. Finally, the fourth study seeks to understand and illustrate the delay in diagnosis of lung cancer patients under Taiwan’s current health care system, and to identify the factors associated with it.
Overall, this dissertation finds that the design of health systems, types of health care services offered, how much people are being offered, accessibility and availability of care, and the seeking behavior of care users all are intertwined and inherently involved with health of the populations. For instance, the poor and the marginalized are still refrained access to care due to geographical distribution of resources and copayments, which increase the mortality risk of preterm or low birth weight babies despite the implementation of the universal health care system in Taiwan. Furthermore, good population health hinges on the provision of primary health care services irrespective of how much was spent on health care in monetary terms and where it comes from, given a certain level of economic development.
While these results provide a good evidence base for the assessment of health in countries, and in specific populations like mothers, preterm or low birth weight newborns and cancer patients, there are weaknesses and limitations to each of the study designs, principally related to the data that was available and the assumptions made. Moreover, future research needs to be undertaken to identify other related upstream factors linking to differential health. |
