转型期中国农村医疗保障制度性缺失分析

【作者】 李丽；

【导师】 陈朝先； 陈苑红；

【作者基本信息】 西南财经大学 ， 金融学， 2004， 硕士

【摘要】 根据世界卫生组织在第53界卫生大会上发表的《2000年世界卫生报告》，在全球191个成员国国家医疗保障制度的公平性排名中，中国排在第188位。中国医疗保障服务在城市和农村人口之间分配严重不公平，约占中国总人口15％的城市人口享用着2／3的医疗保障服务，而约占85％的农村人口却只享用不到1／3的医疗保障服务。我国农村医疗保障制度历史上曾经大面积取得成功且在国际上影响较大的合作医疗，经历了上世纪60年代到70年代的辉煌后，于上世纪80年代走向衰落，农村医疗保障制度出现了制度性缺失的问题。90％的农村人口无法享受到任何一种社会医疗保障，每年有大约1305万的农村人口因病致贫、因病返贫，2003年3月突发的“非典”疫情就充分暴露了我国农村医疗保障制度的脆弱性。无论从农民的医疗保障权利还是从农村社会经济稳定发展的角度来看，建立和完善农村医疗保障制度的必要性和重要性都是不言而喻的。但是，目前我国农村正处于社会经济转型期，经济体制、社会结构以及乡村文化等方面都发生了很大的变化，加上农民收入水平相对很低，区域经济发展很不平衡，医疗服务机构补偿机制市场化，医疗服务价格上涨，贫困地区县乡财政困难，这些都制约农村医疗保障制度的建立和完善。在转型期诸多约束条件下建立一个怎样的农村医疗保障制度以及怎样建立农村医疗保障制度正是本文研究和思考的目的和意义。本文对转型期我国农村医疗保障制度的分析是以时间为线索，按照提出问题、分析问题到解决问题的逻辑思路进行的。首先从对过去失败教训的分析中提出问题，然后从政府、医疗机构以及农民多方面分析当前困境的成因，最后分析制约农村医疗保障制度建设的社会、经济、文化因素，提出未来农村医疗保障制度的模式选择。在分析国际社会尤其是发展中国家成功经验的基础上，对农村医疗保障制度改革进行政策建议，并且针对新型农村合作医疗制度试点中出现的问题<WP=4>提出激励约束机制。全文由前言和四章构成。前言主要介绍本文的研究背景和研究方法，并对研究范围进行界定。当前农村医疗保障制度建设受到政府的大力支持，全国各地都在试点新型农村合作医疗，而且理论界许多资深的经济学家、社会学家、卫生专家等从不同角度对农村医疗保障制度进行了研究。本文的分析是采用制度经济学的方法，将农村医疗保障制度作为一种变量，从历史演进的视角分析，认为农村医疗保障制度是在转型期经济、社会、文化等因素制约下的政策问题、资金问题和信任问题。第一章是对我国农村医疗保障制度的回顾，分别剖析了第一次合作医疗以及第二次合作医疗时期的农村医疗保障制度变迁。本文认为第一次农村合作医疗的产生和发展得益于合作医疗（制度）、三级医疗预防保健网（机构）和乡村医生（人员）构成的“三大支柱”，而伴随着农村合作医疗制度的合作经济基础—集体经济的瓦解、政府强制性行政干预与农民的自愿参与的矛盾带来的制度脆弱性的凸现、以乡村“赤脚医生”维系的乡土亲情的削弱，第一次合作医疗于20世纪80年代末彻底崩溃。第二次合作医疗时期各地在政府的大力支持下积极探索和发展，出现了福利型、风险型、福利风险型等多种形式的合作医疗制度，但是都没能为农民提供有效的医疗保障，加上土地的医疗保障功能又十分微弱，医疗保险实施条件不成熟，我国农村医疗保障存在制度性缺失的问题。第二章对0当前中国的农村医疗保障制度性缺失的问题及成因进行分析。农村医疗保障制度性缺失的问题具体表现为广大农民对医疗保障制度的可及性和可得性很差。农民对医疗保障的潜在需求巨大，不同人群之间以及不同地域之间对医疗保障的需求也有很大差异，但是这些需求很难通过社会化的医疗保障制度转化为有效需求。一方面由于农村医疗设施、人员、资金和制度等方面的不合理配置，我国农民对医疗保障的可及性低下，有病不能得到治疗。另一方面，农民的医疗保障制度呈现低水平和区域差距巨大等状况，加上医疗费用的增长速度高于农民收入的增长速度，农民对医疗保障的可得性低下，有<WP=5>病不敢治疗。由此导致转型期我国农民健康水平改善不大甚至下降，农村因病致贫、因病返贫的人数与日俱增。本章第二节具体分析了导致农村医疗保障制度性缺失的供需双方原因：第一，转型期各级政府对农村医疗保障制度的重视不够，财政投入不足；第二，在分权财政改革背景下的中央与地方政府责任界定不清，在财政资金紧张和没有农民施加压力下的地方政府不愿履行责任；第三，作为需求方的农民以前由于诸多因素未能从农村医疗保障制度中受益，对基层政府以及农村医疗服务机构不信任，失去参与的积极性。所以说，转型期农村医疗保障制度的问题不仅仅是政策问题，资金问题，更是信任问题。在问题和成因的分析基础上，第三章就重建农村医疗保障制度模式进行分析。转型期的农村医疗保障问题是个系统问题，与我国农村经济、政治、社会以及文化的变化息息相关。东、中、西部经济发展不平衡、农民收入的水平和结构多元化要求各地实行不同的医疗保障制度；随着从事非农产业人数的增加以及结构变化，农民出现了分化，在工业化以及城市化进程中逐渐从以家庭保障更多还原

【Abstract】 According to the world health report 2000 published by the WHO, China ranked 188 among the 191 member countries in terms of the medical contribution equality. The resource of the medical security is unequally distributed with more than 2/3 resources given to the 15% city members while the 1/3 left given to the 85% rural members. China’s cooperative medical security system, which was once successfully recommended to other developing countries in the 1960s and 1970s, has been disabled in the 1980s, and the rural members in China are lack of medical security system. 90% rural members are out of the security of social medical security, more than 13.05 million rural members become poor annually because of illness. In 2003, the SARS disclosed the vulnerability of the rural medical security system. It’s very urgent and important to build the rural medical security system. In the transitional period, great change has taken place in China in terms of the economy, the society and the rural culture. The east middle and west part of China are different from each other, the peasants are differently employed, the medical security agents are pursuing profit and the price of the medical rise at a rate faster than that of the income of the peasants, all of which are restricting the building of the rural medical security system. Which kind of medical security system to build and how to build it are the two key points of this essay.This essay is written in time logic, from the analysis of the past failure, I propose the problem; from the present reason analysis, I explore the problem; at last I vision the future medical security system model and propose the detailed measures to realize the model.This essay consists of a preface and four chapters:In the preface, I introduce the background and the method of this <WP=8>essay. Rural medical security system is under great attention of the government and the researchers, and there is trial system in the countryside. But this essay regards medical security system as an institution and analyzes it in the context of history. I think the problem of the rural medical security system is policy problem, capital problem and the inter-belief of the government and peasants in the transitional period.In the first chapter, I retrace the history of rural medical security system and analyze the ups and downs of the first and second cooperative medical security system respectively. The success of the first cooperative medical security relies on the complex of rural doctors and the medical agent system. While the economic basis relapsed in the 1980s and the doctors became profit-hunters, the first cooperative medical security system became over and the second cooperative medical security system began to explore a new way out.In the second chapter, I analyze the situation and the reasons of the problem. Because of the unequal distribution of medical resources and the human resources, the peasants have no access to medical security; because of lack of the medical security system and the price rises faster than the income, the peasants cannot pay the medical security. To explain these difficulties, I think the government was not acting suitably in the transitional period and the local government was not motivated to provide public goods, while the peasants were doubtful about the medical security reform because of the historical failure.In the third chapter, I analyze the constricting factors in the transitional period to rebuild the medical security system and propose a multi-level rural medical security model. I think the government should shoulder the task to finance more for the peasants, let the peasants choose freely and encourage multiple agents to finance and supervise it. In the whole nation, I propose a multi-level medical security system model and different parts of the countryside should choose different model suitable <WP=9>for the special situation.In the fourth chapter, I give some proposals to the building of the medical security system scheme after the analysis of the ref更多还原