【作者】 李德成；

【导师】 高力克；

【作者基本信息】 浙江大学 ， 中国近现代史， 2007， 博士

【摘要】 农村合作医疗兴起于20世纪50、60年代农业合作化高潮时期，它是一种在村庄范围内，实现健康人群与生病人群互助救济的医疗卫生保健制度，它为解决我国农村地区“缺医少药”的落后面貌作出了巨大的贡献。建国初，国家卫生状况十分糟糕，整个国家缺医少药，农村更是如此；而且，当时国家由于经济发展及财力的限制，医疗保障只惠及城镇居民，广大农村居民在没有任何保障的情况下，自发地创建了合作医疗这种医疗保障制度。由于合作医疗制度的实行和推广，以及“赤脚医生”对合作医疗的忠实执行，大大缓解了农村缺医少药的局面，提高了农村居民对基本医疗保健服务的可及性和可得性，显著改善了农村人口的健康水平，被一些国外专家赞为“开创了发展中国家人口大国较好地解决了农村问题”的“中国模式”。但是，80年代后，由于各种因素的影响，合作医疗纷纷解体，大多数地方的农民又回到自费看病的老路，造成有病不看，小病拖大，因病致贫的不良后果，严重影响了农民的身体健康和农村地区的发展。今天，在新一届政府的重视下，新型农村合作医疗正在推行，对过去合作医疗发展的历史经验进行总结，有利于新型合作医疗制度的健康发展。第一章首先阐述了新中国成立初所面临的落后的农村医疗卫生状况，分析了造成这种状况的原因，以及新政权采取的对策。建国初期，整个国家卫生状况十分糟糕，农村更甚，而且卫生资源严重分布不均。新政权面对农村地区十分落后的卫生状况，采取了积极的措施来应对。先是提出了卫生工作“四大方针”，用以指导整个国家的卫生建设，接着整合农村已有的卫生资源组建联合诊所，并派遣城市医务人员到农村巡回医疗，以缓解农村地区缺医少药的困境，与此同时，国家加强了对农村地区医疗卫生机构的建设，着手构建农村三级医疗预防保健网，为农村社会提供适宜的卫生保健服务，使农村缺医少药的状况得到明显改善。三级医疗预防保健网与农村合作医疗制度关系密切，前者是后者的支持体系和实施平台，并为后者提供制度实施的组织保障，后者是其网底和基础。第二章对农村合作医疗的发展历史和组织管理情况进行了分析，对合作医疗制度的历史作用以及合作医疗衰落所造成的后果进行了论述。合作医疗的兴起是在农村合作化高潮时期，其发展是在“文革”期间，衰落是在农村经济体制改革以后。合作医疗的组织和管理大多是以村庄为范围进行，其最明显的作用是遏制和消灭了农村地区的很多传染病、地方病，缓解了农民看医问诊艰难的困境，提高了农民的身体素质，极大地提升了农村居民的预期寿命，促进了社会发展。它的衰落，造成了一系列不良的后果。第三章从多维角度对合作医疗的兴衰原因进行了分析。从合作医疗的历史发展进程来看，其兴衰与中国社会转型及“二元社会”结构模式有关。它的兴起是由于社会经济的变迁以及农民的现实需要，其在短期内能够在全国迅速推广，是因强大政治动员和政府从外部实行干预的结果，它的解体也受政治、经济环境变化的影响。当然，对合作医疗发展最具有决定性的因素，是集权化政府有强大的整合社会资源的能力以及毛泽东的权威。合作医疗能在那样短的时期内迅速推广和普及也是得到了党中央及毛泽东主席强有力的支持，合作医疗的解体也与政府部门改变了毛泽东时代的卫生路线有关。第四章对赤脚医生出现、演进的历史进行了阐述，对赤脚医生现象出现的原因进行了分析，对赤脚医生的管理、培训，合作医疗制度下的医患关系进行了探讨。赤脚医生是合作医疗的忠实执行者，由于有这样一支在农村基层就地培养起来的卫生队伍的辛勤工作，使农村地区落后的卫生面貌大为改观。赤脚医生现象的出现，是当时中国政府为解决农村地区医疗卫生资源缺乏的状况，构建的有中国特色的农村公共卫生体系的产物，符合缺医少药的农村居民的现实需要。由于当时重视对赤脚医生的管理、培训以及医德教育(当时体现为政治思想教育)工作，加上赤脚医生是在一个熟人社会中开展医疗活动，使其能很好地为农民服务，医患关系和谐融洽。当时能在短时期内迅速造就出一支遍布全国的、百万人的赤脚医生队伍，有其可取的经验，对今天乡村医生的培训也有借鉴意义。第五章通过对一个普通村庄——社山村合作医疗发展史的个案分析，可以看出，村庄医疗的发展与政治运作有极大的关联。社山村的村庄医疗兴起于合作化时期，是一种村庄内部自发的行为；而合作医疗的兴起和发展是在当时政治、经济环境下，外来力量干预的结果。在当年政治化的社会空间中，合作医疗被视为两个阶级、两条路线斗争的阵地之一，搞合作医疗是执行毛主席的卫生路线，所以干部群众的积极性很高；加上在当时公社体制下，农民的生产、生活都依赖于集体，由于有集体经济做后盾，使合作医疗得以维系和发展。随着集体经济的解体、公社体制的解散，在没有外来力量的干预下，社山村的合作医疗也就瓦解了。从村庄医疗的兴衰原因可以看出，干部和政府对农村问题的关注程度，直接影响农村社会的发展状况。最后余论部分对当时的合作医疗和新型合作医疗进行了比较研究，从历史经验中总结出了一些对新型合作医疗发展中应注意的问题。新型合作医疗应该在以人为本的理念指导下，将新型合作医疗的举办纳入到公共卫生体系的建构中，打破城乡“二元社会”壁垒，实行城乡一体化的医疗保障模式，发展全民医疗保险，平等地保障每个公民的健康权，这样才能更好地促进社会发展。更多还原

【Abstract】 Rural cooperative medical system rose in 1950-1960 when rural cooperatives was in climax, it was a medical and sanitarian safeguard system by which healthy crowd and ailing crowd helped or relieved each other in the range of villages, and it have made tremendous contribution to solve laggard visage of rural area lacking of doctors and medicine. At the beginning of establishment of the republic of China, the sanitarian status of the whole country was so bad and the whole country lacked of doctors and medicine, even worse in rural area; what’ s more, because of the limit of economic progress and the power of wealth, the medical safeguard system only benefited the dwellers of towns and cities. The dwellers of villages spontaneously set up this cooperative medical safeguard system without any safeguard. This cooperative medical system was enforced and spread and barefoot doctor loyally enforced this system , which largely alleviated the status of lacking of doctors and medicine, made village dwellers get in time and acquire for basic medical sanitarian service , remarkably improved the healthy level of rural population , so this system was praised as "Chinese mode " by foreign experts which better solves the rural problems in developing country of huge population. But after 1980, cooperative medical system dismissed one by one because of all kinds of factors, the peasants in most of places returned back to pre-situation in which they saw doctors at their owns’ expenses, so brought the side effect, namely, they didn’ t go to see a doctor when they were ill, indisposition aggressively became serious , and they became poor caused by illness, thus seriously affected the health of peasants and the progress of rural area. Today, new cooperative medical system which the new government attaches importance to is pushing. Summarizing historical experience of cooperative medical system in the past benefits the healthy progress of new cooperative medical system.The first chapter firstly expounds the laggard medical sanitarian status of rural area at the beginning of establishment of the republic of China, reviews the reason that brought about this status and the countermeasure that the new government have taken. At the beginning of establishment of the republic of China, the sanitarian status of the whole country was very bad, even worse in rural area, and the distributing of health sources was seriously not even. The new government took active measures when confronted with this laggard status. Firstly, advanced "four principles" of sanitarian work to guide sanitarian construction of the whole country, next, integrated the exist rural sources to construct union cliniques, and sent the medical workers of cities to the rural area , thus alleviated the rural status of lacking of doctors and medicine. At the same time, the state strengthened the construction of medical sanitarian institutes in rural area, began to construct the third grade rural network of medical immunity and sanitation, which offered available medical sanitarian service for rural society and distinctively improved the status of lacking of doctors and medicine. The third grade rural network of medical immunity and sanitation and the rural cooperative medical system are tightly related, the former is the support system and actualized stage of the latter and offer the organization safeguard of system actualized for the latter, the latter is the basis for the former.The second chapter reviews the progress history and organization and management status of rural cooperative medical system and discusses the historical function of cooperative medical system and the outcome caused by the decline of this system. It rose in the climax period of rural cooperatives, developed during the cultural revolution, declined after the rural reformation of economic system. The organization and management of cooperative medical system carried through in the range of villages, its most distinctive function was to prevent and annihilate many infectious and endemic diseases, alleviate the rough plight of the peasants seeing the doctor, enhance the peasants’ body diathesis, largely advance due life-span of rural dwellers, and to promote the social development. Its decline caused a series of ill aftereffect.The third chapter analyses the reason of rising and declining of cooperative medical system from multidimensional angle. Seen from history development cause of this system, its rising and declining are related to Chinese social transformation and "dualistic society" structural mode. It rises because of the variance of social economics and practical need of peasants, it can quickly spread in the whole country in a short time because of strong political mobilization and government’ s outer intervention and its disaggregation is affected by change of political and economical circumstance. Of course, the decisive factor to the development of cooperative medical system is the ability to integrate social sources of centralized government and the Mao Zedong’ authority. The reason why it can quickly be spread and popularized in such a short time is the strong support by central government and chairman Mao, and its disaggregation is related to government department who has changed the sanitarian route of Mao Zedong period.The fourth chapter expounds the history of appearance and course of barefoot doctor, reviews the reason of appearance of barefoot doctor phenomenon, and probes into the relationship between doctors and patients in cooperative medical system and the management and training for barefoot doctor. Barefoot doctor was loyal executors to this system and the laggard sanitarian visage was largely changed in rural area because of the arduous work of such a sanitarian group who was trained in rural basis on the spot. The appearance of barefoot doctor phenomenon was the outcome of central government who tried to solve the status of lacking of medical sanitarian sources in rural area and designed the Chinese characteristic system of rural pubic sanitation, and accordance with the practical need of rural dwellers of lacking of doctors and medicine. Central government attached importance to the work of management and training for barefoot doctor and education of morality (mainly embodied by political thought education then), furthermore, barefoot doctor worked in an acquaintance society, thus they could service for the peasants better and the relationship between doctors and patients was harmonious. Such a great barefoot doctor group consisted of millions of people throughout the whole country could be quickly trained in such a short time then, which had advisable experience and it can give reference to today’ s training for rural doctors.The fifth chapter educes that development of rural medical system is largely related to political operation through a case study, namely, the course of cooperative medical system of a general village called SheShan. Rural medical system of this village rose in the period of rural cooperatives, and it was a spontaneous inner action; the rising and development of cooperative medical system was the outcome of outer intervention in the political and economic circumstance of the time. In the politicalized society space of the time, cooperative medical system was looked as one of positions where two class and two route battled. Cooperative medical system enforced the Mao’ s route, so enthusiasm of cadre and crowd was high, furthermore, the production and existence of peasants depended on collectivity in the community system of the time, thus cooperative medical system could maintain and develop because of backing of community economics. With the disorganization of community economics and the disbandment of community system, SheShan village’ s cooperative medical system disintegrated without outer intervention. We can conclude from the reason of rising and declining of this village that the extent of cadre and government’ s attention to the rural problems directly influences developing status of rural society.Finally, in conclusion part the former cooperative medical system is comparatively searched with new cooperative medical system and it is concluded that some problems should be given attention in the development of new cooperative medical system. New cooperative medical system should integrate its conduct into the construction of public sanitarian system under the guidance of people—oriented conception, break the "dualistic society" bulwark between cities and countries, enforce medical safeguard mode of integrating cities with countries, develop civil medical insurance and equally ensure the health right of every citizen, only through these measures can social development advance better.更多还原