【作者】 何含兵；

【导师】 罗长坤；

【作者基本信息】 第三军医大学 ， 社会医学与卫生事业管理， 2013， 博士

【摘要】 背景与意义：近年来，在新公共服务管理改革浪潮的影响下，以及鉴于政府卫生直接投入的“低效益性”和“软约束性”，通过公共购买筹资实现政府由基本卫生服务的直接生产者向购买者、推动者和监管者等“能促型”角色的转变，逐步成为许多国家卫生服务改革的主流方向。在中国，尤其在2009年新医改之后，公共购买筹资也逐渐引起政府和学界的关注。但是，该制度在我国尚处于试点起步阶段，不可避免带有制度模仿或移植的烙印，既往文献多囿于某个孤立点上对实践的解释，而忽略了对购买效果评价、策略设计以及后续保障的系统深入研究，且缺少从机理层面结合实证对话的深入分析与诠释。因而未能给政府制定服务购买筹资政策提供科学的、可操作性的理论依据，致使现行购买机制运行不畅，效果不明显，最终导致了基本医疗卫生服务的效率低下、质量不佳、可及性弱等绩效问题。而且无论是实践还是学理研究均主要局限于城市社区卫生服务和住院服务，对村卫生室这种与农民关系最为密切、最基层的领域极少涉及。因此，系统研究农村卫生室公共购买筹资政策，理顺政府投入机制，优化服务效率和质量，促成资源的帕累托改善，对推进农村基层医疗卫生体系的可持续性发展，提高农村居民基本医疗卫生服务的可及性具有重要的战略实践和理论价值。研究方法：本研究基于经济学和公共政策学视角，主要运用文献研究、规范研究、实证研究、比较研究等方法。在充分把握当前农村卫生室等基层卫生机构公共购买筹资的改革研究现状的基础上，分析比较国内外公共购买筹资不同实践模式的特征，利用委托代理理论厘清其中各方的利益关系及互动机制，运用制度变迁理论和议程设置理论缕析卫生室融资制度的历史变迁逻辑，结合贵州实证数据，采用准实验对照法评估现行公共购买筹资政策对卫生室的激励约束效应，并利用鱼骨因果法剖析其中存在的问题及根源，在此基础上以政策循环理论、循证卫生政策和鱼骨对策法为理论框架对卫生室公共购买筹资机制策略进行系统设计。此外，还利用IDEF0技术构造购买筹资的操作流程，基于博弈论构建政府与卫生室的非对称信息动态激励约束模型，最后采用SWOT-PEST理论对该政策策略的可行性予以分析。目的与内容：本研究旨在探讨贫困地区村卫生室公共购买筹资政策的有效激励和约束机制，为政府制定村卫生室补偿与融资策略，解决卫生室发展中的资金瓶颈问题提供理论和实证依据。主要内容包括：(1)研究基层卫生机构公共购买筹资理论与实践。把握公共购买筹资的内涵与外延，分析不同购买模式的特征，并基于委托代理理论厘清其中各方主体(购买方、供方、需方)之间的利益关系与互动机制。总结国外的实践经验。(2)研究我国农村卫生室公共筹资政策制度变迁。以农村经济制度和财政体制的演变为主线，从纵向的、历史的角度考察建国后我国农村卫生室公共筹资政策的变迁逻辑，总结历史的经验教训。(3)评价现行农村卫生室公共购买筹资成效，并进行问题诊断与归因。结合贵州省24个国家级贫困县的实证数据，评估当地公共购买筹资政策对卫生室服务提供的激励效应，围绕基本医疗卫生系统的效率、质量与可及性三个绩效维度，剖析其中存在的主要问题，并从组织体制、资源配置、支付机制和治理规制四个层面追踪问题根源。(4)系统设计村卫生室公共购买筹资政策策略。针对基本医疗卫生服务效率、质量、可及性等绩效问题，以参与约束和激励相容约束为主要原则，设计代表需方利益且能对卫生室产生良性激励的公共购买筹资系统策略，并从系统运作角度，构建公共购买筹资的操作流程以及购买双方之间的非对称信息动态激励约束博弈模型。最后，对该政策策略的可行性及其面临的威胁和挑战进行SWOT-PEST分析。研究结论：(1)卫生机构公共购买筹资是对政府直接投入的传统服务提供模式的变革，有利于供方激励竞争机制的形成。其主要包括合同制和凭单制两种基本方式，总体而言，采用合同制中的独立关系竞争模式可在买卖双方建立一种基于法律保护程序的责权明晰的问责机制，更有利于制约供方的机会主义行为，提高公共购买效率和质量。公共购买筹资中存在着三种委托代理博弈关系，即政府与公众之间的公共权利委托关系，政府与供方之间的契约责任委托关系，以及供方与公众之间的基于公共购买行为的一种延伸服务责任关系。各委托方总是基于一定的策略机制影响代理方的行为，以实现自身效益目标的最优化。国外实践表明，卫生机构公共购买筹资提倡市场竞争机制与政府宏观调控体制的有机融合，强调服务购买与服务提供功能的分离以及购买双方平等的契约关系，注重对公众健康权利需求的积极响应以及对供方激励相容机制的重塑。(2)我国农村卫生室公共筹资的制度变迁是一个在特定社会经济和政治宏观环境下，政策研究者、决策者、利益相关者以及媒体的互动博弈过程，是一个从均衡到非均衡再到均衡的螺旋上升式的循环演化过程，历经了合作社、人民公社、家庭承包责任制三个历史变迁阶段，其议程模式经历了从动员模式到内参模式再到以压力模式为主的多种模式组合的转化。整个演化轨迹显示：村卫生室的补偿模式在思想上逐渐由以生产要素为基础的直接投入转变为开始考虑探索多种形式的补偿(包括公共购买筹资)；民主化决策与利益相关者之间的博弈均衡程度有利于缩小卫生筹资政策与社会经济发展之间的时滞差距，促进筹资制度的可持续发展。(3)贵州省现行公共购买筹资政策初步显示了其对村卫生室发展的潜在驱动力。但同时存在着基本医疗卫生服务效率低、质量不佳、可及性弱等绩效问题。其根源在于购买筹资政策设计的不合理及相关配套保障机制的缺失，主要体现在：组织体制，缺乏民主、畅通的需方诉求表达机制，购买主体人为割离且统筹管理层级偏低，购买双方存在着较强的隶属依赖关系，卫生室服务能力先天不足且缺乏公平有序的竞争环境；资源配置，重住院(大病)轻门诊，重高层轻基层，服务包代表性不强；支付机制，不合理的支付方式以及低水平的支付价格弱化了对供方的激励约束力；治理规制，法治赤字、规程缺失以及监管乏力导致服务购买绩效的进一步恶化。(4)针对农村卫生室公共购买筹资中存在的问题，设计了一套购买筹资机制策略，主要包括：①组织策略。在村、乡、县三级分别建立村民管理小组、购买监事会和绩效考核委员会；将公共卫生、基本医疗和贫困医疗救助三个购买机构横向整合到社会保障部门，将管理统筹层级纵向提升至省级；对乡村两级机构明确定位，建立村医首诊和双向转诊制，增强卫生室服务能力，营造多元化竞争格局。②资源配置策略。调整购买服务包内容(包括10类公共卫生服务和4类基本医疗服务)；门诊和住院统筹基金之比提高到3:7；村级门诊报销比例提升到70%，单次封顶线调整到15元；提高村卫生室的公共卫生经费分配比重(50％左右)。③支付策略。综合运用预付和后付制激励元素，建立基于绩效的包括按人头支付、按项目支付、总额预付制和基本薪酬制相结合的复合支付方式；适度提高整体支付水平，以满足村医总体收入的外部公平性、内部公平性和自身公平性。④治理规制策略。建立专门的卫生服务公共购买筹资法律体系，规范操作流程，并基于买卖双方的博弈均衡点优化政府治理监督。(5)对村卫生室公共购买筹资政策策略的SWOT-PEST分析显示，该政策策略符合当前国家卫生改革发展的方向和需要，政策实施所需经济资源能在现实中获得满足，能够取得社会相关利益主体的认同和接受，通过努力能在现有技术上达成政策目标。同时，该政策策略也面临着政府监管能力较弱、市场竞争有限、交易成本增加等威胁和挑战。(6)提出了建立和完善我国农村卫生室公共购买筹资机制的政策建议。主要包括：①跨越观念误区，实现政府服务职能与角色转型。②整合提升政府购买部门，促进部门间的横向协作。③建立村、乡、县三级民管机构，畅通需方诉求表达渠道。④提高卫生室激励响应能力，培育多元化准竞争市场。⑤优化资源配置，提高卫生室公共购买筹资的覆盖范围和水平。⑥创新支付策略，提升基本医疗卫生服务整体绩效。⑦合理核算成本，保证公共购买资金的有效利用。⑧强化治理规制，保障公共购买筹资政策目标的实现。更多还原

【Abstract】 Background and Significance：Over recent years, it has been a mainstream model of health service reform in manycountries to transform the role of the government as a basic health service producer into"enabling" roles, such as purchaser, promoter and regulator, through public procurement, underthe waves of public service administration reform and given the low cost-effectiveness and softconstraint of direct government investment. In China, the public purchase financing has drawnattention from the government and academia, particularly after the new medical reform in2009.However, at the pilot stage, this system is inevitably branded with signs of imitation ortransplanting, and past literatures focused on a single point in interpreting the practice whileneglected systemic and in-depth research on purchase result assessment, strategy design andsubsequent assurance, and lacked in-depth analysis and explanation at the principle levelcombined with empirical evidence. The failure to provide scientific and maneuverable theorybasis for government to promulgate purchase financing policies renders the existing purchasemechanism unsmooth and ineffective, resulting in low efficiency, poor quality and weakaccessibility in basic medical and health service. Besides, both practice and theoreticalresearches are limited to urban community health service and hospitalization service, whilerarely involving village health clinics, which are the most basic and most closely related tofarmers. Therefore, it is of significant practical and theoretical value to systematically study thepolicies on financing through public procurement for rural health clinics, smoothen thegovernment investment mechanism, optimize service efficiency and quality, and facilitatePareto optimization of resources, so as to promote sustainable development of the ruralgrassroots medical and health system and increase the accessibility of basic medical services torural residents. Research Methods：From the perspectives of economics and public policy studies, this study adoptsliterature research, normative research, empirical research and comparative research, amongothers. Based on a full understanding of the status quo in research on reform of publicprocurement financing at grassroots health institutions, such as rural health clinics, this paperanalyzes the characteristics of different practical models of public procurement financingdomestically and abroad, clarifies the stakes of all concerned parties and interactivemechanism using the Principal-agent Theory, and determines the logic of historical evolutionof health clinic financing systems by using the Institutional Evolution Theory and AgendaSetting Theory. Based on the practical data of Guizhou, this paper assesses the incentive andconstraint of the existing public procurement financing policies on health clinics by using theQuasi-experimental Case-control method, and analyzes the existing problems and rootcauses by using the Fishbone Diagram. Based on these, the paper carries out systematicdesign of the financing mechanism with a theoretical framework composed of the PolicyCycle Theory, Evidence-based Health Policy and Fishbone Countermeasures. Besides, wecreate the operation process for procurement financing with IDEF0technique, build theasymmetric information dynamic incentive and constraint model between the governmentand health clinic using the Game Theory, and finally analyze the feasibility of the strategyusing the SWOT-PEST theory.Purpose and Content：This study is intended to discuss the effective incentive and constraint mechanism ofpublic procurement financing policies for health clinics in impoverished areas, to providetheoretical and practical bases for the government to formulate compensation and financingstrategies for village health clinics and solve the financial bottlenecks in the development ofhealth clinics. The paper contains the following:(1) Study on the theories and practice of public procurement financing of grassrootshealth institutions. In this part, the paper analyzes the characteristics of different ways ofprocurement and models, and clarifies the stakes and interaction among all parties(purchaser, supplier and demander) based on entrusted agent theory. These will be followedby a summary of the practical experience abroad.(2) A study of the evolution of public financing policies of rural health clinics in China. In this part, we examine the evolution of the public financing policies of rural health clinicsin China from a vertical historical perspective and summarize historical lessons, alongsidethe evolution of rural economic and financial systems.(3) An assessment of the effect of the existing public procurement financing on ruralhealth clinics and problem diagnosis and cause identification. Based on the practical datafrom the24national impoverished counties of Guizhou Province, we assess the incentive oflocal public procurement financing policies on health clinic service, analyze the problemsaround three dimensions of the efficiency, quality and accessibility of the basic medical andhealth system, and track the root causes of the problems in terms of organizational system,resource allocation, payment mechanism and governance rules.(4) A systematic design of the public procurement financing policies and strategy ofvillage health clinics. To address performance issues such as the efficiency, quality andaccessibility of basic medical and health service, etc., we design a public procurementfinancing system strategy (organization, resources, payment, and regulation) in the interestof the demander and with positive incentive to the health clinic, and build the operatingprocess of public procurement financing and the asymmetric information dynamic incentiveconstraint model between the parties. Finally, we conduct SWOT-PEST analysis of thefeasibility of the policy strategy and the threats and challenges it is facing.Research Conclusions：(1) As a reform of the conventional service provision model of direct governmentinvestment, the public procurement financing of health institutions facilitates the formationof the supplier incentive and competition mechanism. This includes contract-based andvoucher-based approaches. In general, the independent relationship competition model ofcontract-based approach establishes an accountability mechanism with clear liabilities andbased on legal protection procedure between the transaction parties and better constrainsthe opportunistic behavior of the supplier and improves the efficiency and quality of publicprocurement. In public procurement financing, three entrusted agent game relationshipsexist, namely the entrust relationship between the government and the public, thecontract-based entrust between the government and supplier, and an extended serviceliability relationship based on public procurement between the supplier and the public. Theclients always influence the behavior of the agent based on a certain strategy mechanism for optimal attainment of their benefit goals. As indicated by practice abroad, for publicprocurement financing of health institutions, it is favorable to promote organic integrationof market competition mechanism and government macro control, emphasize on separationof service procurement and provision functions and the equal contractual relationshipbetween the buyer and seller, actively respond to the demand of the public for health rightsand reshape an incentive and compatibility mechanism toward the supplier.(2) In China, evolution of the mechanisms for rural health clinic public financing is aprocess where policy researchers, decision makers, stakeholders and media interact andcompete with one another under specific socioeconomic and political circumstances. This isalso a circulation evolution process of spiral ascendancy from balance to imbalance, and tobalance again, evolving from cooperatives, People’s Commune, and family contractors, and theagenda model evolves from mobilization to internal reference, and to the pressure model. Thewhole evolution process indicates an ideological shift from direct spending based onproduction factors to exploration of diverse forms of compensation (including publicprocurement financing); democratic decision-making and game equilibrium degree betweenand among stakeholders will help reduce the latency between health financing policies andsocioeconomic development and facilitate the sustainable development of the financing system.(3) The existing public procurement financing policies of Guizhou have shown apotential boost to the development of village health clinics. However, they are plagued byperformance problems like low efficiency, poor quality and weak accessibility of basicmedical and health services. The root lies in inappropriate policy design and absence ofauxiliary assurance mechanisms, specifically: In terms of organizational structure, ademocratic and smooth mechanism for the demander to express is absent; the purchaser isartificially alienated and located at a low integrated management level; the purchaser andseller are highly dependent; the service capability of the health clinic is congenitally weak,and a fair and orderly competitive environment is absent; in terms of resource allocation,priority is attached to hospitalization (major disease) rather than outpatient service, and tohigh levels rather than grassroots, and the service package is poorly representative; in termsof payment mechanism, unreasonable terms of payment and low prices weaken theincentive and constraint on the supplier; in terms of governance rules, deficit in the rule oflaw, the absence of rules and insufficient regulation cause service procurement performance to further deteriorate.(4) We have designed a mechanism strategy specific to the public procurement financingof rural health clinics, consisting of:①Organizational strategy. At the levels of village,township and county, the villager administration group, procurement supervisory board andperformance review committee are established; the three procurement entities of public health,basic medical service and poverty medical relief are horizontally integrated to the socialsecurity authority, and the management integration level is lifted to the provincial level; atwo-level structure should be clarified in townships, establish village doctors first diagnosedand two-way referral system, enhance the service capability of the health clinic and shape adiverse competitive landscape.②Resource allocation strategy. The procurement servicepackage is adjusted (including10categories of public health service and4categories of basicmedical service); the proportion of outpatient to hospitalization funds is lifted to3:7; theproportion of village-level outpatient reimbursement is increased to70%, and the ceiling of asingle transaction is adjusted to RMB15; the proportion of public health expenses of thevillage health clinic is lifted (to about50%).③Payment strategy. Through comprehensiveutilization of pre-payment and post-payment incentives, a performance-based compositepayment method consisting of capitation, fee for service, global budget and basic salary isestablished. The overall payment should be appropriately lifted to achieve external, internal andintrinsic fairness of compensation of village doctors.④Governance rules strategy. It isadvisable to establish a special legal system for health service public procurement financing,standardize the operating procedure and optimize governance monitoring based on the gameequilibrium point between the two parties of the contract.(5) As indicated by SWOT-PEST analysis of the public procurement financing strategyof village health clinics, this strategy meets the orientation and need of national healthreform development, the economic resources required for implementing the policy areavailable in reality, the strategy is recognized and accepted by stakeholders, and policyobjectives can be achieved with existing technology through efforts. Meanwhile, thisstrategy is also threatened and challenged by weak government regulation, limited marketcompetition and increasing transaction cost.(6) We have recommended policies for establishing and improving public procurementfinancing mechanism of rural health clinics in China. These include:①To transform the government’s function and role by discarding outdated ideology.②To integrate governmentprocurement departments and facilitate horizontal collaboration across departments.③Toestablish a three-level civil administration structure encompassing the village, township andcounty, and smoothen the channels for service users to express opinions.④To enhance thehealth clinic’s responsiveness to incentive and develop a diverse quasi-competitive market.⑤To optimize resource allocation and expand the coverage and capability of publicprocurement financing of health clinics.⑥Develop innovative payment strategy andimprove the overall performance of basic medical and health services.⑦To calculatereasonable costs and ensure effective use of procurement funds.⑧To strengthengovernance regulation (improve capability building of the procurement entity, establish adiverse and3D close-looped monitoring and constraint mechanism, establish a dynamic andphase-based performance review system, enhance repeated cooperation to build a trustassurance system among various parties and enhance health education to the public).更多还原