【作者】 李宁；

【导师】 秦富；

【作者基本信息】 中国农业大学 ， 农业经济管理， 2005， 博士

【摘要】 本文的研究是基于以下背景提出的:1、农村医疗卫生保障制度的缺乏使得农民因病致贫、因病返贫的比例提高;2、改革开放前以农村合作医疗为主体的医疗保障制度被世界卫生组织誉为发展中国家解决卫生保障的唯一典范,改革开放后中国的农村卫生却被世界卫生组织引为卫生政策的反面案例,仅20年世界卫生组织对中国卫生的评价出现巨大的反差;3、目前对农村医疗卫生保障制度的研究多是从社会学、卫生经济学角度展开,多侧重于技术研究,而忽略了对制度环境的研究。 本研究在详尽阐述医疗卫生服务产品属性的基础上,指出了农村医疗卫生保障制度政府支持的必然性,构建了经济学的分析框架。首先运用制度经济学的理论与方法分析了合作医疗制度的变迁;然后,从供给和需求角度对我国农村医疗卫生服务的现实状况进行了实证研究,并分析了农村医疗卫生保障的现状;第三部分对正在进行的农村新型合作医疗制度进行了研究;第四部分根据以上分析对影响农村医疗卫生保障制度的影响因素进行了总结,最后提出了相应的政策建议。 研究表明改革开放前后合作医疗制度的开展的绩效情况,从正反两方面揭示了合作医疗制度在农村地区取得发展和良好绩效需要的各种条件,其中政府的支持极为关键。合作医疗制度的建立和发展,是与农村经济体制、农村卫生体制的变化紧密联系在一起的,这是农村基层卫生组织与合作医疗制度曾经取得成功运作的制度基础。着重预防、健康教育、环境卫生工作是低成本但高效益地提高农村健康保障的基本规律。 农村卫生服务供求现状分析研究表明在卫生总费用上城乡之间无论从总量来说,还是从人均数来说,城乡之间存在较大差异,卫生费用的分配存在“偏城市、轻农村”的现象;从农村卫生总费用的分析来看农村居民个人支付比例不断提高,国家对农村卫生的投入主要用于补贴服务供方,而且主要用于机构的运转,对需方补助少;从两个调研县的分析来看,中国中西部地区的部分县达不到农村人均卫生费用的平均水平,国家应予以重视。县、乡、村三级医疗机构是农村医疗卫生服务的主要提供者,通过对调研县的分析发现部分乡镇卫生院的利用效率在下降,存在以药养医的状况。村级医疗卫生机构是农产处理日常疾病主要机构,其提供的服务有的属于公共物品的范畴,国家却对村级医疗卫生机构财政支持较少,这与卫生服务的需求不相匹配。从卫生可及性来说,西部地区的卫生可及性较差。公共卫生城乡差异巨大,农村内部地区差异也有扩大趋势。 1990年-2003年农户的医疗卫生服务量增加不大;农村居民的医疗服务利用率下降,农产的收入水平成为决定医疗服务需求的关键因素;疾病成为农民因病致贫、因病返贫的主要原因。 农民的正式医疗保障制度覆盖率低,家庭保障等非正式制度的保障能力有限,农产对医疗卫生保障制度需求强烈。 要使新型合作医疗持续下去,要建立农产与政府之间的信任机制。要实现农村新型合作医疗制度下卫生服务的有效供给,必须加大对农村基本医疗设施的支持力度,尤其要改善乡镇卫生院医疗条件,加强对乡镇医务人员的培训,提高乡镇医务人员的技术水平,满足农民对医疗的基本需求,确保新型农村合作医疗达到预期目标。农村新型合作医疗制度对大病补偿作用有限,为提更多还原

【Abstract】 The research is proposed under the background as following: Firstly ,since 1990’ s diseases have become one of major reasons resulting in poverty in rural China with absence of the rural medical security system. Secondly cooperative medical system (CMS) before the system transformation was praised by WHO while is criticized by WHO after system transformations.Finally most research are often carried out from the point of sociology and hygiene economics , there are few researches on the system circumstance. So this research has important meanings in theory and reality.Based on elaborating the good character of rural health service the paper points out that it is essential for the government to establish the health care and medical security system. From the above the author establishes the economic framework . Firstly the paper analyses the transition of CMS using the theory and methods of institutional economics. Secondly the paper analyses the supply and demand of rural medical service and the reality of medical security system. Thirdly the paper analyses the new cooperative medical system (NCMS). Fourthly the paper analyses the facter affecting the health care and medcial security system . At last some relevant policy implication are suggested.The study shows the importance of government support from the comparative analysis of CMS .The establishment and evolution of CMS is connected with the change of economic system and health system of rural China . The study holds that the expenditure of health care resources has obvious local difference and difference between town and country . From the analysis of medical expenditure of rural China , the proportion of farmers expenditure is higher than before while the disbursement of the government is lower. From the research of the two counties ,we can concludes the medical level of some countries in central and west China are below the average. County hospital township health centre and the village clinics are primary medical service provider in rural China. The utility of the resources in township centre is in low efficiency .The study of public health service in rural China implys the seriously insufficient in some rural areas and it resulting in "medical service was feeded by the medicine ".The village clinics are the key providers to cope with indisposition. Some medical services of it belong to public good while there is few financial subsidy on it. The supply of public health has apparent difference between town and country and there is an expanded tendency of different areas in rural China.The quantity of medical in rural China has few change from 1990 to 2003. The utility of medical service of farmers is declining. The level of income is an important factor affecting health of farmers and it is also the bottleneck which restricts farmers using medical service . Illness becomes the key factor resulting in poverty. The coverage of formal medical security syetem is low in rural China and the informal system provides limited medical security in rural China .The confidence mechanism should be established between farmer and the government .The township medical centre should be given more financial support in order to realize the effective medical supply. The NCMS has limited inpact on coping with serious illness. If high particition rate is simplychased with household account, the NCMS is not CMS in principal. The financial disbursement ability is a key factor in NCMS and it is not suitable for poverty rural area.The financial constitution the difference of areas the income of farmers and the rural medical provider systems are important factors in establishing rural health care and medcial security system. At last some relevant policy implications are suggested.更多还原