【作者】 陈昱方；

【导师】 张亮；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2011， 博士

【摘要】 研究目的“金砖国家”是指巴西、俄罗斯、印度和中国这四个新兴的市场经济国家,也是正处于转型中的大国。国家转型的核心是政治、宪政规则的大规模改变与经济体制上的重大改革,而卫生体制只是转型的一部分。本研究旨在总结“金砖四国”卫生体制改革及其运行机制等文献资料和相关经验总结的基础上,分析比较“金砖四国”的医疗卫生体系、制度和制度模式及其政治、经济发展等条件的相关性。通过分析比较,在研究未来医疗卫生体系发展变化趋势的基础上,根据我国国情,结合中国未来经济社会中、长期的发展规划和全面建设小康社会的目标,提出当前医疗卫生体系改革和完善的思路和政策建议,为建立适应中国国情的医疗卫生制度体系服务。研究方法(1)文献分析法通过文献分析,归纳总结国际、国内已有研究成果,在此基础上,确立本论文的理论框架体系、明确研究方法及指标。通过查阅相关政策条文、统计数据等资料信息,全面了解“金砖四国”的医疗卫生制度体系。(2)比较分析法本研究将大量采用比较分析法,通过比较定量、定性地区分差异、判断优劣,增强预测性,并提供有效政策借鉴。“金砖四国”的医疗卫生制度体系及其具体国情,国家医疗卫生制度体系建立、发展的社会经济背景和制度运行的状况,以分析的方法进行归类,以比较的方法进行研究,总结相关的发展规律,为中国卫生体制改革提供实践经验。(3)专家咨询法收集和整理所调查国家的卫生事业发展的相关报表、报告和其他资料,同时,通过对多个国家的医疗卫生领域专家进行咨询和访谈,讨论卫生改革内容,过程及成效以及未来改革的方向等问题。(4)历史分析法以时间为主轴,重现过往的事实,具体分析金砖四国国家转型的这一具体的时间段,主要着眼于四国国家政治、经济和社会的结构性变迁中,医疗卫生体制的重大变化,然后加以归纳与总结。研究内容国家转型是一个长期的、不断发展的过程。直到现在,“金砖四国”的经济都还在转型之中。本研究以“金砖四国”的医疗卫生体系为研究范围,以制度分析为研究主线,从历史发展的角度出发,研究卫生体制在国家政治、经济和社会的结构性变迁中的制度形成和演变的过程以及其中的重要推动力量,在对“金砖四国”医疗卫生体系进行深入分析和剖析的基础上,对各国的医疗卫生制度进行比较研究。本研究以“金砖四国”的医疗卫生体系为研究范围,以制度分析为研究主线,从历史发展的角度研制度形成和演变的过程,从政治、社会和经济背景研究制度的理论基础,在分析医疗卫生体系的基础上,对其配套的制度进行比较研究。(1)比较和分析“金砖四国”的医疗卫生制度产生的背景、制度形成和演变的过程。(2)比较和分析“金砖四国”的医疗卫生体系的优点及缺点,总结其经验教训。(3)比较“金砖四国”的医疗卫生体系、制度等的内部相关性以及他们和社会经济、政治、文化等条件的外部相关性。研究结果(1)一个国家卫生保健体制建立和完善,不仅取决于经济发展水平,更取决于政府的政治意愿和社会价值取向。(2)国家卫生保健制度不能只采取单一的模式,而是根据本国国情,借鉴国际经验,确定一种模式为主体、多种模式共存的复合型保健制度。(3)政府是推动医疗卫生体制改革的决定性力量,在建立和完善卫生保健体制中发挥主导作用。(4)扶持推动改革的动力,是加快医疗卫生体制改革的重要手段。结论(1)遵循“低水平、广覆盖”的原则,建立覆盖全人群的医疗保障制度。调动国家—市场—社会三方的共同力量,建立由政府、单位、社会、个人多方共同筹资、强制参保的社会医疗保险体制,真正体现医疗保险的公平性和互济性。(2)建立“政事分开、管办分离”的管理体制和法人治理的公立医院治理结构。建立公立医院出资人制度,解决国有资产产权主体虚位问题,实现管办分离。在基本医疗服务体系中应保证公立医院的主导性,明确政府对公立医院的财政支持、高效管理责任,推进基本医疗服务的可及性、公平性。制定法律法规,允许社会资金参与社会公益事业,兴办非营利性、营利性的医院,使之成为公立医院的重要补充,考虑通过购买服务的形式来将其纳入基本医疗服务体系,积极鼓励公立医疗机构和私立医疗机构建立合作伙伴和公平竞争关系。(3)通过扶持推动改革的动力来加快改革进程。中产阶级是提升国家健康水平的核心力量,应当通过完善医疗保障制度体系和提高教育的普及性,减少贫困人口,扩大中产阶段的数量,构建市民社会。同时,政府应积极引导农民形成自身群体组织,提高农民的自组织程度,完善农民的利益表达机制和方式,畅通和拓宽农民利益表达与沟通的公共渠道以充分反映其利益诉求。研究特色与创新之处(1)比较全面地对“金砖国家”转型中的医疗卫生体制进行了系统研究。对上述国家的政治环境、卫生筹资方式、组织管理、资源配置、服务提供、财务风险分担等,从各国制度沿革变迁的历史轨迹来总结和比较各国卫生体制改革的经验和教训,尚属国内首次对“金砖四国”卫生体制系统全面的阐述与比较。(2)考虑了时间、制度以及政治和社会等因素,对国家转型中医疗卫生体制的复杂演化做出系统解释。通过比较和分析“金砖四国”卫生体制改革存在的共性问题,以及问题的解决方式与基本思路,定量、定性地区分差异、判断优劣,增强预测性,并提供有效政策借鉴,是国内首次对相关国家卫生体制系统深入的针对性比较和分析研究,得出的结论具有较高的科学借鉴意义。(3)本研究通过分析推进改革深入和促进制度变迁的动力机制,发现统治精英、市民社会和中产阶级是推动医疗卫生体制改革的重要动力,因此扶持农民利益团体、扩大中产阶级数量及加强私立医院的发展将有利于促进医疗卫生体制的良性发展,本研究所提出的政策建议新颖,对于当前医疗卫生体系改革有较高的参考价值。更多还原

【Abstract】 Research purposesBRIC countries" refers to Brazil, Russia, India and China, four large emerging market economies in transition. The core of the transformation of a country is the large-scale institutional changes in political, constitutional rules and major economic system, and the changing in health system is just part of the transformation. This study aimed to summarize the "BRIC" health system and its operational mechanism and relevant literature on the basis of lessons learned, analysis and comparison of the "BRIC’s" health systems, the system model and its political and economic development and other related conditions. Through analysis and comparison and the study of future trends in health system development and based on China’s actual conditions, combined with China’s future economy and society, long-term development planning and goal of building a moderately prosperous society, this research makes the current health system reform and improve ideas and policy recommendations for improving of China’s health care system system services.Research Methods(1) litrature analysis Through literature, summarized the international and domestic research results, on this basis, this paper established the theoretical framework of the system, a clear methodology and indicators. Through access to relevant policy provisions, statistics and other data and information, a comprehensive understanding of the BRIC countries health system system.(2) comparative analysis In this study, extensive use of comparative analysis, by comparing the quantitative and qualitative differences between sub-regions, to determine the strengths and weaknesses, enhance predictability, and provide a valid policy reference. From China, India, Brazil, Russia and China BRIC system and its health system specific national conditions, national health system, establishment of a system, the development of socio-economic background and status of system operation, in order to classify the methods of analysis to compare methods of research, summarizes the development of related laws, the Chinese health system to provide practical experience.(3) The Delphi methodCollection and collation of the survey the development of national health-related statements, reports and other information at the same time, through multiple countries to consult medical experts in the field and interviews to discuss health reform content, process and effectiveness and future direction of reform the problem.(4) Historical analysisUsing historical record and a detailed analysis of the BRIC countries at that specific transiting period, primarily focusing on four countries in the political, economic and social structural changes, the health care system, major changes, and then summarizing findings.Research contentIn this study, China, India, Brazil, Russia, the BRIC countries and China’s health care system for the study of the scope of institutional analysis for the study of the main line of development from the perspective of historical development, degree of formation and evolution of the process, from the political, social and economic background the theoretical basis of the system, making health care system, BRIC-depth analysis and analysis based on a comparative study of two systems. In drawing on China, India, Brazil, Russia, the BRIC countries, based on lessons learned, the design of future institutional system of health care framework, proposed a reform and improve the current system of health care system reform ideas.(1) analysis of China, India, Brazil, Russia and China(BRIC) health care system in the background, analysis of their system formation and evolution process.(2) building performance evaluation of China, India, Brazil, Russia, BRIC’s health care system for comprehensive and objective evaluation.(3) analysis and comparison of China, India, Brazil, Russia, BRIC health system strengths and weaknesses to summarize the lessons learned.(4) through the analysis and comparison of China, India, Brazil, Russia, BRIC’s health care system, the system of internal as well as their relevance and socio-economic, political and cultural conditions of the external dependencies. According to China’s national conditions, combined with China’s future economy and society, long-term development planning and community health objectives by the current health system reform and improve the ideas and policy recommendations.The results(1) establish a national health care system and improvement depends not only on the level of economic development, but also depend on the political will and social values.(2) national health care system can not only take a single model, but according to their national conditions, drawing on international experience, to determine a model for the dominant and diverse modes of complex health care systems coexist.(3) In establishing and improving health care systems play a leading role. The more developed the economy, the government’s public funding accounted for the greater proportion of total health expenditure, government expenditure on health accounted for the total government budget, the greater the proportion of expenditures.(4) National health care system is largely the same basic functions.Conclusions(1) follow the "low level and wider coverage" principle, establish the whole people health care system. To mobilize countries-market-the collective power of social three parties, set up by the government, the unit, the society and individual DuoFang common fundraising, forced ginseng protect social medical insurance system, and reflect medical insurance of fairness and sex of each other aid.(2) Establish a "separate management office politics, separation" management system and of corporate governance of the public hospital governance structure. Establish a public hospital system for investors, solve the property right of state-owned assets absent subject and realize management office separation. In the basic medical service system in a public hospital should guarantee the dominant sex, clarifying government to public hospital financial support, efficient management responsibility, promote basic health care to the accessibility and fairness. Make laws and regulations, allow to social capital to participate in social public welfare and the establishment of the non-profit, for-profit hospitals, make it become the important supplement of the public hospital, consider the form of service by buying into the basic medical service system, and actively encourage public medical institutions and private medical agency partners and fair competition relations. At the same time to establish China’s all-around doctor system, cultivate all-around doctor team, set up corresponding incentive mechanism, which enables the general practitioner in the community to long-term service, the realization "gatekeeper" role, gradually to the doctor’s more practice.(3)Through the support to promote the momentum of reform to speed up the reform process. The middle class is raising the national health level of the force at the core, shall be through the perfect medical security system and improve the education system of popularity, the reduction of poverty population, and expand the number of middle stage, the construction of the civil society. At the same time, the government should actively guide peasants to form their own group organization, improving farmers’ self organization level, perfect the interests of farmers expressing mechanism and method, clear and broaden the interests of expression and communication channels to fully reflect the public interests and needs. Research features and innovations(1) more fully on the "BRIC" transformation in the health care system has been systematically studied. Political environment of these countries, health financing, organization and management, resource allocation, service delivery, financial risk-sharing, etc., from the evolution of national systems to track changes in the history of summary and comparison of national health reform experiences and lessons learned, is still China’s first times on the "BRIC" health system, the system comprehensive exposition and comparison.(2) to consider the time, institutional, and political and social factors, the national health system in transition to make the system to explain the complex evolution. By comparing and analyzing the "BRIC" health system common problems, and problem solving with the basic ideas, quantitative, qualitative differences between sub-regions, to determine the strengths and weaknesses, enhance predictability, and provide effective policy learning, is the first sub-systems of the countries health systems targeted depth comparison and analysis, concluded that high scientific reference.(3) to promote reform in this study was to analyze in depth and dynamic mechanism to promote institutional change, that the ruling elites, civil society and the middle class is to promote health system reform, an important driving force, so to support the interests of farmers groups, to expand the number of middle class and strengthen the private Hospital development will help to promote the sound development of health systems, policy recommendations proposed in this study is novel, for the current health system reform has high reference value.更多还原