【作者】 张建平；

【导师】 罗剑朝；

【作者基本信息】 西北农林科技大学 ， 农业经济管理， 2006， 博士

【摘要】 长期困扰中国人民的“短缺经济”时代已经变为“相对过剩”,人民的吃饭问题已经基本解决。但是,面对农民卫生费用的不断攀升,农村卫生机构服务质量低下,因病致贫返贫现象的不断增加,面对全面建设小康社会、和谐社会的宏伟目标,如何建立起一个人人可及而又有效的农村医疗卫生体制,解决农民就医难就医贵的问题已成为理论界和实践界的当务之急。本文在系统深入总结国内外相关文献的基础上,回顾了我国农村合作医疗制度的变迁过程,探讨了国外医疗制度的有益经验,从我国农村医疗市场的供给与需求、农村合作医疗的运作模式、农村合作医疗的运行机制以及农村合作医疗制度改革的难点与障碍四个方面分析了农村医疗供给的有效性、现行制度的保障水平等问题,运用管理学、经济学理论,针对性地提出了制度供给、体系建设、机制保障等在内的一系列政策建议,对于构建新型合作医疗制度、解决农村医疗卫生的供给不足问题以及医疗卫生体制的改革具有重要的理论意义和现实意义。全文共由九章主体内容组成:第一章,导论。阐述了中国农村合作医疗制度的选题背景、选题目的及意义,全面分析了国内外相关研究,明确了研究重点和方向,并对研究思路与方法及可能创新之处做了必要的说明。第二章,农村合作医疗制度的基础理论。医疗服务作为一种健康消费品决定了医疗市场的特殊性,即它的不确定性、信息不对称和外部性,这些特性直接导致了该市场无法满足帕累托最优所需要的条件。本部分详细讨论了疾病风险理论、社会保险理论、医疗市场失灵与政府干预理论、合作经济理论、农村医疗社会保障理论等,为后续内容做了坚实的理论铺垫。第三章,中国农村合作医疗制度的演变历程及现状。合作医疗自产生起,历经发展、辉煌、衰退、再发展几个阶段,反反复复几经周折,曾经被世界卫生组织誉为“发展中国家解决卫生经费的唯一范例”,但到2002年又沦落为卫生系统“财务负担”最不公平的国家之一(191个国家排名188位)。本部分总结概括了中国农村合作医疗产生发展的变迁过程,探讨了其衰退原因,对新型合作医疗制度作了基本评析,指出了其缺陷,主要是财政补贴与自愿参与挂钩,易形成逆向转移支付;保大不保小,增加了逆向选择风险;农民并未能切实得到实惠;费用控制困难等。第四章,国外医疗制度及启示。要建立完善的农村合作医疗保障制度,借鉴它国经验是必须的。本章主要探索其各自的主要做法与优缺点,研究、总结国外农村医疗保障制度建设过程中的经验与教训。其经验主要有:明确政府在卫生领域的功能和职责;充分发挥非政府组织及市场机制的作用;提高卫生资源筹资的渠道和效率;建立支付制度的内在激励机制等。这些有益经验对建立和完善我国农村医疗保障制度具有重要参考价值。第五章,中国农村医疗市场的供求分析。医疗市场特殊,中国农村医疗市场由于城乡二元经济结构表现尤为明显。本部分从总体角度、供给角度、需求角度、供需均衡角度分别予以论述,基本结论是:医疗需求不能有效满足、医疗供给状况不佳、政府投入不足、农民医疗负担沉重。如何进行适当的制度安排,使农民看得起病,这是政府及社会不容推辞的责任。第六章,中国农村合作医疗模式。合作医疗的目的不在于“为合作而合作”,因而即便包括新型合作医疗在内的各类合作医疗模式不可避免的具有缺陷。本章分析了影响合作医疗模式的因素,探讨了我国合作医疗的模式创新思路和未来发展趋势,为政府选择适宜的医疗改革模式提供借鉴,对促进城乡医疗卫生体系的一体化具有十分重要的意义。第七章,中国农村合作医疗运行机制及评价。资金筹集是合作医疗制度建设的首要和根本问题,而补偿与激励约束问题又直接关系到农民的积极性与该制度的持续性,合作医疗制度的有效运行有赖于筹资机制、补偿机制以及激励约束机制。本部分探讨了合作医疗筹资机制的演进与构建原则,提出了相关改进措施;分析了合作医疗补偿机制的内涵与原则,对现行模式做了客观评价,指出了选择补偿模式应注意的问题;从农民、管理人员、医疗服务提供者角度提出了激励机制,重点探讨了对医疗机构、医疗服务质量与合作医疗基金的约束机制——强化监管。第八章,中国农村合作医疗改革的制约因素及障碍。合作医疗改革是一项复杂的系统工程,涉及到国家(中央政府)、地方政府、医疗机构(含管理部门)和农民等多个主体,改革难度与障碍既大又多。本部分从各个主体入手,对其各自的经济行为进行了深入剖析,指出了各自的不足之处。分析认为,国家的主体责任发挥不够、地方政府财力紧张、医疗机构忙于逐利、农民收入低下且信心不足是其重要原因,为合作医疗改革的方向和突破口选择以及重点的把握提供了理论依据。第九章,中国农村合作医疗制度改革的总体方案与配套措施。本部分在探讨合作医疗性质的基础上,通过制度变迁理论和模型分析,指出合作医疗制度改革的路径选择应该是强制性制度变迁;认为制度供给层面应该内外部制度建设并重,其中内部制度建设的重点是道德和价值观的培育,而外部制度建设则涵盖了政府财政投资制度、医学人力资源制度、医院独立董事制度等多个方面;体系建设方面提出了三级预防保健网的重建思路;配套措施方面重点讨论了以远程医疗解决农村医疗资源不足、看病难的有效举措。从制度供给、体系建设、机制保障与配套措施等方面提出了一系列政策建议。更多还原

【Abstract】 The“Shortage Economy”age, which had harassed the Chinese people for a long time,is evolving into a“relative surplus”one;the problem of feeding the people has been solved. However,the farmer’s expenses on medical treatment are continuously increasing; and they are served by low-quality medical institutions in the rural areas. There are more and more cases of causing poverty by diseases. Thus, aiming at building an integrated, comparatively well-off and harmonious society, it is urgent for the theorists and practitioners to build an effective and extended rural medical service system and to solve the problem of farmer’s expensive hospitalization. In this dissertation, I, on the basis of summarizing relative literature both home and abroad, reviewed the evolution of the cooperative medical service system in China’s rural areas, studied the beneficial experiences of the medical service system abroad, and analyzed the validity of rural medical supply and ensuring level of present systems from four aspects, namely, the supply and demand of China’s rural medical market, the operating pattern of rural cooperative medical service, the operating mechanism of rural cooperative medical service as well as the cruxes and rubs in rural cooperative medical service system reform. Meanwhile, theories of management science and economics are applied pertinently to help advance a series of policy suggestions including systematic supply, system construction and supervision of constitutions. This plays a very significant role in building a new type of cooperative medical service system, in solving shortage supply of rural medical service and in reforming medical and health-care systems of China.The dissertation is composed of nine chapters.Chapter one is the introduction. In this chapter, I expatiated the background and significance of selecting this topic, the cooperative medical service in China’s rural areas, analyzed in an all-round way the relative studies both home and abroad, determined the study pivot and direction, and made indispensable explanation on study clues and methods as well as the possible innovations.Chapter Two is on the basic theories of rural cooperative medical service system. Medical service, as health consumer goods, determines the particularity of the medical market. In other words, its nondeterminacy, dissymmetry of information, and exteriority directly cause market’s failing to satisfy the requirements demanded by Pareto-optimality. In this part, theories such as those of disease risk, social insurance, medical market failure and state intervention, cooperative economy as well as rural medical service social security, were discussed in detail, which paved a solid way for developing the following content.Chapter Three is on the evolution and status quo of the cooperative medical service in China’s rural areas. Since its birth, cooperative medical service has undergone four phases, namely, growing, refulgence, declining and re-growing. It was once praised by the WHO as“the sole paradigm of developing countries to come up with medical and health-care outlay”. But in 2000, China was reduced to one of the most unfair“financial burden:”countries in the health-care system, being .No. 188 among the 191 countries. This part summarizes and epitomizes the change of the cooperative medical service system in China’s rural areas, probes into the reasons of its declination; it also makes a preliminary appraisal and analysis on a new type of cooperative medical service system and pointed out its defects. The defects include: reverse payment transfer caused by financial subsidy and volunteer participation, bigger reverse choice risk, failing to favor the farmers and difficult controlling of expenses, etc.Chapter Four is on medical service systems abroad and their revelations. It is indispensable to use the experiences of developed countries for reference, if we desire an improved rural medical service system. This chapter mainly studied the basic ways and their advantages and disadvantages of foreign countries in dealing with medical service and security matters, probed into and summarized the beneficial experiences and lessons from foreign countries during their building rural medical service and security systems. The successful practices include: clarification of government’s function and duties on public health, a full play of the roles of non-governmental organizations as well as of market mechanism, expansion of the channels and efficiency of fund-raising for public health, and building of an interior stimulating mechanism of payment. These good practices are very significant references for China’s rural medical security.Chapter Five is on supply-demand analysis of China’s rural medical market. China’s rural medical market is very particular because of its city-countryside binary economic constitution. This chapter discussed this from four angles, namely, general, supply, demand and equilibrium of supply and demand respectively. The conclusion is that the medical demand cannot be satisfied effectively, that the medical supply is in a very bad condition, that there is shortage of investment by the Government, and that the farmers suffer from very heavy medical burdens. It is the bounden responsibility of the Government and society to coordinate related systems and arrangements so as to provide the farmers with favorable medical security. Chapter Six is on China’s rural cooperative medical service patterns. The aim of cooperative lies not in“cooperation for cooperation’s sake.”Therefore, all kinds of cooperative medical service patterns is endowed with inevitable defects. This chapter analyzes the factors influencing cooperative medical service patterns, and to probe into the innovative ways and future developing trend of China’s rural cooperative medical service patterns. This is significant to supply references for the Government to choose fitting medical service reform mode, and to promote the integrity of city-countryside medical and health-care system.Chapter Seven is on the operating mechanism and it evaluation of China’s rural cooperative medical service. Fund-raising is the first and fundamental problem in cooperative medical service, while compensation, stimulating and check is directly related to the farmer’s enthusiasm along with the duration of this system. Therefore, effective operation of cooperative medical service system relies heavily on fund-raising mechanism, compensation mechanism and stimulating and check mechanism. This part probes into the evolution and constitution principles of the fund-raising mechanism of cooperative medical service, put forward related improving measures, analyzes the connotation and principles of the fund-raising mechanism of cooperative medical service, evaluated objectively the present pattern, and pointed out the problems that should be noted when choosing compensation mechanism, put forward stimulating mechanism from the angles of the farmer, the managerial personnel as well as the medical service man, and mainly discussed the check mechanism for the medical institutions, medical service quality and cooperative medical funds—intensifying supervision and management.Chapter Eight is on the rubs in China’s rural cooperative medical service reform. Cooperative medical service reform is a complicated, systematic program, which involves several subjects such as the State (the Central Government), local government, medical institutions (including medical managing departments), and the farmers. There are many and hard cruxes and rubs. This part proceeded with each individual subject, anatomized its individual economic behaviors and pointed out their inadequacy. It is discovered that the State did not make a full play of its subject responsibility, that the local governments are beset with small financial capacity, that the medical services are busy with their own profits, and that the farmers are lack of confidence because of low income; they are the main reasons. This discovery provides a theoretical basis for cooperative medical service reform to choose the direction, the breach and the pivot.Chapter Nine is on the overall scheme and supportive measures for China’s rural cooperative medical service system reform. On the basis of studying the nature of cooperative medical service and with system change theory and model analysis, I pointed out that approach choice of cooperative medical service system reform should be a forced system change. It held that the system supply level should put stress on both its interior and exterior system construction; the pivot of its interior system construction lies in cultivation of morality and values, while its exterior system construction covers several aspects such as government financial investment system, medical labor resources system, and hospital independent directoration system. A three-level prevention and health-care network is suggested to strengthen system construction. Some effective measures are put forward as supportive measures, such as to use distance medical service to make up the insufficient medical resources in the rural areas. A series of policy suggestions are put forward from aspects like systematic supply, system construction, mechanism ensuring and supportive measures.更多还原