【作者】 王伟；

【导师】 冯学山；

【作者基本信息】 复旦大学 ， 社会医学与卫生事业管理， 2013， 博士

【摘要】 研究背景农民作为“三农”问题中的首要问题,也为核心问题,其健康是关系到我国社会发展的根本问题。医疗保障制度则为维护农民健康,发挥着非常关键作用。我国农村的医疗保障制度发展经历了漫长而曲折的探索过程,从上世纪60、70年代的辉煌,到80、90年代的衰退,导致95%以上的农民又回到“谁看病、谁掏钱”的自费医疗老路,许多农民因无力承担医疗费用而无法获得基本医疗服务,因病致贫、因病返贫现象严重。为解决我国农村居民的医疗保障问题,2002年中央政府提出,建立以大病统筹为主的新型农村合作医疗制度(新农合)。2003年起,新农合开始试点,至2012年底,全国参合农民达8.05亿,参合率98%。新农合的迅猛发展,取得了明显效果,保障范围与保障水平不断提高,但同时仍有不少问题妨碍着制度的健康发展。如何保证新农合的可持续发展是制度所面临的首要问题,也是核心问题。通过文献复习了解到,较多已有研究是从某个方面或某个角度对新农合制度展开研究,而从新农合制度各个主体的角度,并结合社会经济环境,对新农合制度本身的筹资、补偿支付、监管等各个部分进行分析,探讨新农合制度可持续发展的系统综合性研究则相对较少。因此,本论文期望从可持续发展的视角,以新农合制度为研究对象,通过理论与实证的系统综合分析,探寻影响新农合发展的制度内外因素,提出新农合制度可持续发展的政策建议。研究目标基于可持续发展视角,通过对新农合制度的筹资、补偿、监管以及制度外环境的系统综合分析,以期为推进新农合制度从“制度建立”向“质量提升”转变,促进新农合制度可持续发展提供思路和政策建议。具体目标：1从可持续发展视角,对合作医疗制度的发展历程进行回顾分析,探讨成功与失败的原因,总结其经验教训,为新农合制度的健康持续发展提供借鉴。2从可持续发展视角,利用相关理论对新农合制度本身及其制度环境进行理论分析,探索实现新农合制度可持续发展的相关因素。3利用全国新农合制度运行资料,描述新农合制度的实施状况,分析新农合制度可持续发展存在的问题。4利用我国西部某省三县新农合制度实施的案例资料,分析其新农合制度发展过程中的运行状况以及存在的问题,探讨影响新农合制度可持续运行的相关因素。5综合理论及实证案例分析结果,提出实现新农合制度可持续发展的政策建议。研究方法1资料来源(1)文献资料通过中国知网、OVID等专业文献数据库以及Google学术搜索引擎,以“新型农村合作医疗”“可持续”"new cooperative medical scheme""sustainable development"“集体化时期合作医疗”“传统合作医疗”等为主题词／关键词进行组合检索合作医疗研究相关文献。收集自2002年以来中央政府出台的新农合相关政策文件,以了解新农合制度的政策进展及实施情况。(2)现有宏观数据资料收集2006-2010年中国统计年鉴、中国卫生统计年鉴及2006-2010年全国新农合信息统计手册。(3)案例资料本研究收集的案例来自于欧盟资助项目“在中国和越南建立公平性和可持续性农村健康保障制度研究”。该项目根据新农合实施情况、兼顾地理分布和经济水平以及当地政府自愿参与研究的原则,选取宁夏回族自治区中宁县、青铜峡市和永宁县3个县(市)作为研究现场,于2006年开展新农合基线调查,调查方法包括定量调查、定性调查和现有资料收集,调查对象包括农民、卫生服务提供者、新农合管理者、行政决策者。之后根据调查结果设计新农合干预方案,并自2007年1月起在3个项目县(市)进行实施,于2008年开展新农合终末调查,调查对象与方法同基线调查。2研究方法(1)系统分析法新农合制度建设是一项复杂的系统工程,涉及到各级政府职能部门,医疗卫生机构、以及农村居民等多个主体,并且新农合制度是整个社会保障制度的一个子系统,而社会保障制度又是整个社会的一个子系统。因此,新农合制度的建立和完善,不仅取决于新农合本身的制度设计,而且受到整个国家的政治、经济、文化等社会环境因素的影响。本研究采用系统分析法,结合多个主体的视角,对制度本身和外部环境进行综合系统分析,探讨影响新农合制度健康持续发展的相关因素。(2)历史分析与比较分析本研究通过回顾合作医疗制度发展历程,从可持续发展视角,剖析其制度的自身设计及制度环境,探讨其成功和失败的经验教训。将新旧合作医疗制度发展进行比较分析,揭示其中差异,为当前新农合制度可持续发展提供启示。(3)理论分析和实证分析本研究基于可持续发展视角,运用制度经济学、福利经济学、卫生经济学及社会保障等理论对新农合制度设计、运行机制进行理论分析,并结合全国新农合制度运行数据以及宁夏回族自治区三个县案例的实证分析,为推进新农合制度可持续发展提供科学证据。(4)现有资料分析与现场调查研究本研究通过查阅和梳理合作医疗相关的专业文献,了解合作医疗制度已有的研究成果；通过收集政府有关新农合制度发展的政策文件,了解国家政府对新农合发展的方针政策；通过收集全国新农合运行数据,分析新农合实施情况及存在问题。本研究的案例资料中,在宁夏3个项目县分别展开了现场调查,包括机构的定量调查以及对供方、需方和管理方的定性调查,收集了3个项目县新农合的开展情况以及供方、需方和管理方对新农合的看法与建议等现场资料,为深度分析提供基础。(5)定性研究与定量研究本研究案例分析中,采用定性与定量相结合的研究方法。对宁夏3个项目县新农合运行的相关数据进行定量分析,并结合对3个项目县的供方、需方及管理方的定性访谈,综合分析宁夏项目县新农合可持续发展的现状和问题。研究结果1农村合作医疗制度发展历程回顾分析主要结果旧的农村合作医疗制度是建立在集体经济基础上,依托人民公社,依靠低成本的医疗服务供给系统,满足了当时农民的基本医疗需求,提供了低水平的医疗保障,虽然制度安排本身存有缺陷,但由于当时领导者的高度提倡,国家政策倾斜,形成的强大政治支持环境,高度行政集权,使得缺陷没有明显暴露,达成某种均衡状态,制度得到建立与发展。但实质上,社会发展中遇到的问题如果都是集聚社会所有资源去解决的话,那可能就没有不能解决的问题,但在现实中,这种状况只可能是短期行为,不具有可持续性。上世纪70年代末农村经济体制改革,我国的社会经济环境和医疗卫生服务体系发生了巨大的变革,这种均衡状态被打破,使得合作医疗制度迅速走向衰退。可见,制度发展正如经济发展一样,如果它脱离制度环境,无论是超越还是滞后于环境的发展,制度都是难以持续的,这正是可持续发展内涵核心,强调共同协调发展。2理论分析主要结果新农合制度是具有中国特色的初级社会医疗保险制度,政府在新农合制度建设和发展中应承担主导责任,包括组织引导、制度规划、财政支持、管理监督与立法责任；新农合制度筹资标准设计应考虑与农村居民的人均年收入、人均年医疗费用支出以及政府财政收入相匹配。各级政府筹资责任应更加明确,尤其是中央政府和省级政府应承担起更多责任；随着新农合筹资水平的不断提高,新农合补偿模式可向福利风险型转变,补偿方案设计应考虑当地的经济、医疗服务体系及医疗服务供给者的特点、农民的消费特点等制度外环境因素,并注意与其他相关制度的衔接。构建多元化混合支付体系,是当前控制医疗费用迅速上涨,保持新农合基金平衡的有效措施。卫生部门作为新农合的主管部门,其双重身份一定程度上制约了其执行力,影响管理效果,可以考虑逐步整合社会保障部门资源,利于节约管理资源。农村地区的城镇化、人口老龄化、疾病谱变化、医疗保障需求的多样化等问题给未来新农合发展带来挑战,城乡一体化的医疗保障体系亟待建立。3全国新农合运行现况分析主要结果全国新农合制度发展迅速,覆盖面不断扩大,2011年农民参合率己达97.5%,全国农村基本建立新农合制度,新农合筹资水平也逐步提高,已由2006年的人均52元增加到2011年的246元,新农合的受益面及受益水平不断提升,参合农民人均补偿额由2006年的38元上升到2011年的206元,人均受益次数则由2006年的0.66上升到2011年的1.58。但同时仍然存在筹资水平相对较低,筹资来源有待优化,补偿水平偏低等问题,故在今后新农合发展中,中央财政支持力度可进一步加大,农民个人筹资责任适当加强,个人缴纳额度可适当提高,更好发挥集体经济资助的作用,不断提高新农合补偿水平和保障能力。4宁夏三县新农合案例分析主要结果2006-2008年宁夏3项目县(市)新农合筹资标准逐年提高,个人缴费从每年10元提高到20元,各级政府补助从40元提高到80元,个人缴费占农民年人均纯收入的比重均小于0.5%。农民参合意愿显著提高,参合率逐年上升,2009年3项目县(市)参合率都超过90%,在增加补偿比例的前提下,农民愿意提高个人缴费额度。2005-2007年宁夏3项目县(市)新农合实行门诊家庭账户与住院统筹相结合的补偿模式,随着新农合制度发展及其社会环境的变化,2008年开始,宁夏3项目县逐步转变门诊补偿模式,门诊统筹逐步取代门诊家庭账户。2005-2008年宁夏3项目县(市)每年进行住院补偿方案调整,降低住院起付线,取消费用分段,提高住院补偿比例,提高封顶线；3个项目县(市)住院补偿人次和受益率均逐年提高,但农民疾病经济负担仍较重,尤其是大病负担。总体而言,2006-2008年宁夏3项目县(市)农民住院就诊趋向选择县级医院,乡镇卫生院缺乏一定吸引力。可能由于住院补偿方案的不同设计,3项目县(市)住院流向变化呈现不同趋势。同期,不同医疗机构次均住院费用呈现上升趋势,对医疗机构的费用控制缺乏科学有效监管手段,加之管理部门自身监管能力的不足,使得监管效果有限。政策建议1强化政府主导责任,明晰各级政府职责内容2建立稳定长效的筹资机制,逐步提高新农合统筹层次3继续大力推进门诊统筹,制定科学合理的补偿方案4加快开展支付方式改革,构建适宜的支付体系5整合社保机构资源,加强新农合管理能力建设,完善监督管理机制6加快新农合法制化建设步伐7统筹新农合与卫生服务体系的协调发展,优化新农合制度的外部环境更多还原

【Abstract】 BackgroundThere is a long history of the development of rural medical scheme in China. From the1960s to1970s, Rural Cooperative Medical Scheme covered more than90%of rural residents, but it collapsed in1990s. In2003,79%of rural residents were not covered by any health insurance. Many of them had no access to basic health care services because of economic reason and impoverished due to disease.In order to solve this problem, the central government initiated to build up a New Cooperative Medical Scheme (NCMS). The aim is to effectively relieve rural residents’ disease burden, to solve the problem of impoverishment due to disease and improve health. Since2003, NCMS has been implemented in pilot counties. By the end of2012, NCMS had covered0.81billion rural residents, with coverage rate of98%. As NCMS developed rapidly, there were some problems emerged blocked the development of NCMS. So, how to solve these problems to ensure NCMS developed sustainably is a key issue.This study employs normative and empirical methods to explore factors influencing on the implementation of NCMS based on sustainable development perspective, and provides evidences for the development of NCMS.ObjectivesBased on sustainable development perspective, this study aims to analyze the design and implementation of NCMS and its environment comprehensively by a combination of normative and empirical approaches, to provide systematic evidences for the development of NCMS.Specific objectives are as follows:1. Based on sustainable development perspective, to understand the history of development of Cooperative Medical Scheme and analyze the reasons for its success and failure; 2. Base on sustainable development perspective, to explore factors impacting on development of NCMS by normative method employing the theories of institutional economics, welfare economics, health economics and social security;3. To describe the situation of NCMS implementation and to explore the problems influencing the development of NCMS by national existing data based on quantitative analysis;4. To analyze the implementation of NCMS and its impact factors by case study base on quantitative and qualitative data of NCMS collected from Ningxia Province in China;5. To provide policy recommendations for sustainable development of NCMS combining normative and empirical analysis.Methodology1. Data source1.1Second-hand data collectionLiteratures and policy documents on NCMS were collected in order to understand research process, research achievement and policies concerning NCMS. Quantitative data describing the implementation of NCMS in China were collected in order to know about the development situation of NCMS.1.2Case collectionThe case was selected from the project "Bringing health care to the vulnerable: development of equitable and sustainable rural health insurance in China and Vietnam" funded by EU. The overall aim of this project was to promote equity in health by making evidence available for health policy makers for an effective, sustainable and affordable rural health care financing system in China and Vietnam.According to geographic and economic situation, three counties, Qingtongxia, Yongning and Zhongning, in Ningxia were chosen as project sites. In the three counties, two large-scaled field investigations on NCMS were conducted in2006and2008, including quantitative and qualitative survey. The survey respondents included rural residents, health services providers, health administrators and policy makers. 2. Research methodsThe development of NCMS is a comprehensive and systematic project. There have government, health services providers, and rural residents involved this project. NCMS is a sub-system of social security system, which is a sub-system of society. So not only the design of NCMS but also the political, economic and social factors have impacts on the development of NCMS.This study employed system analysis method, historical and comparative analysis, normative and empirical approaches, literature review and field study, quantitative and qualitative study to explore the factors influencing the development of NCMS from multiple perspectives, to analyze the design and implementation of NCMS and its environment comprehensively, and to provide recommendations for the development of NCMS.ResultsNCMS is a kind of primary social medical insurance with Chinese characters. The government plays a leading and important role for the development of NCMS, which should be responsible for design and planning of NCMS, financial support, supervision and management of NCMS, legislation.The NCMS premium should be suitable to local economic situation and meet the health demand of rural residents. The leading responsibility of the government for NCMS should be strengthened, and different responsibility of the government at all levels should be clarified.As the NCMS fund increase rapidly, family account of NCMS should be replaced by the unified fund for outpatient reimbursement. The design of reimbursement protocal should keep the NCMS fund balance strictly. Meanwhile, the characters of local economic status, health system, health services providers and rural residents’ consumption should be considered. The mixed payment system should be established, which will be good for cost control and keeping the NCMS fund balance.Because of "dual identity", the executive power of the department of health is limited to management of NCMS. The department of social security should be gradually responsible for management of NCMS, which will be better for utilization of the resources of management.The challenge caused by urbanization, aging, the change of disease pattern and diversification of health demand should be emphasized, which need to build up a unified health insurance system characterized by multiple levels and urban and rural coordination.The NCMS premium increased year by year in project counties in Ningxia, from10to20CNY for individual premium and from40to80CNY for government subsidies. The rural residents’willingness to pay for NCMS improved significantly. The coverage rate of NCMS expanded year by year and the coverage rate in three counties in Ningxia exceeded90%in2009.The pattern of unified fund for inpatient reimbursement and medical saving account for outpatient reimbursement was implemented in project counties in Ningxia during2005-2007. With the development of NCMS in project counties, medical saving account would be cancelled, and the model of unified fund for outpatient reimbursement would be employed.The reimbursement schemes of NCMS were adjusted annually in project counties in Ningxia during2005-2008. The deductible was decreased, the scheme of reimbursement by segment was changed, and the reimbursement rate and the ceiling were increased. The number of enrollee received reimbursement increased year by year and the enrollees got more and more reimbursement from NCMS in project counties in Ningxia. But the medical expenditure burden was still heavy for rural residents.In general, enrollees tended to county level hospitals for hospitalization in project counties in Ningxia, and the township level hospitals were unattractive to rural residents. On the whole, in project counties in Ningxia, medical expenditure per hospitalization in different level hospitals increased annually. The supervision of hospitals was implemented mainly by administrative means, and the effects of cost control were not good. More economic means of supervision should be employed and the reform of payment system should be carried out.Recommendations1. Strengthening leading responsibility of the government for NCMS, and identifying different responsibility of the government at all levels2. Establishing dynamic and rational financing mechanism to ensure the NCMS fund increasing, increasing the coordination level gradually and realizing the integration of urban and rural health insurance system3. Carrying out co-payment for out-patient services and designing scientific and reasonable compensation protocol of NCMS4. Accelerating the payment reform and building scientific and feasible payment system of NCMS5. Strengthening the capacity building for NCMS management and formulating strict and efficient supervision and management mechanism of NCMS6. Speeding up the legislation process of NCMS7. Coordinating NCMS and health system development harmnionsly, strengthening connection between NCMS and supplementary insurance and improving the external environment of NCMS更多还原