【作者】 尚丽岩；

【导师】 韩毅；

【作者基本信息】 辽宁大学 ， 经济史， 2008， 博士

【摘要】 农村合作医疗关系着农村人口医疗保障水平、农村经济发展和社会稳定。兴起于20世纪50、60年代农业合作化高潮时期的农村合作医疗制度,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,取得“以最少投入获得了最大健康收益”的“中国模式”的辉煌。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。如今,为了解决广大农民因病致贫、因病返贫的问题国家又推行了新型农村合作医疗制度。这一制度经历了从产生发展到高潮再到衰落恢复重建,最终实现制度创新。而创新的过程又并非一帆风顺,曲折反复。在这个制度变迁的过程中,除了环境的改变,人的认知也在发生着变化。诺思指出,为了真正理解人们的行为,理解制度以及制度的变迁需要通过认知科学、经济学、政治学、法学、社会学以及相关的分析来解决问题。本文在研究前人文献的基础上,运用以“以认知为基础”的制度变迁理论,讨论制度演变过程中当事人的认知和行为。力求以个体认知心理研究为基础来揭示制度演进的过程、性质和路径,并把其作为理解制度绩效的关键。探求出这一制度变迁过程产生的根本原因。从而从一个全新的视角去解释农村合作医疗制度变迁产生的过程和原因。本文内容大致安排如下:首先是本文的序论部分,主要阐述文章写作的意义、研究假设、研究主体和研究时间的界定以及篇章结构和创新点。第一章是本文研究的理论基础,认知、学习与制度变迁的相关理论。第二章是关于中国农村合作医疗制度的产生与发展。对合作医疗的产生、发展做了详细描述,这一时期的合作医疗经历了农民实验—媒体报道—政府重视—领导指示—政府推广的过程。从认知视角来分析这一阶段农村合作医疗制度产生发展的原因。信念是制度变迁的内在因素,当毛泽东的个人信念上升为社会信念之后,合作医疗制度也取得了良好的绩效。第三章是对农村合作医疗衰落与恢复重建的分析。政府偏好的改变、基层政府与中央政府共同利益的丧失以及农民自我意识的觉醒、乡村医生医德认知度的下降共同导致了共享心智模型的解体。而在恢复重建的过程中由于认知的停滞和认知路径依赖的作用又使制度陷入到内卷化的状态之中。第四章是新型农村合作医疗制度的推行,即制度的创新。制度危机的出现推动了制度创新。但由于政府的有限理性、农民的理性不及以及农民自身的预期、对政府信任度的下降,定点医疗机构的态度等原因导致新型农村合作医疗制度推行之初并不顺利,但随着政府认知的调整以及农民认知行为的调整,新型农村合作医疗制度逐步趋于完善。并对认知模式与制度创新的关系进行了分析。第五章是对合作医疗进一步发展的对策。包括构建合理认知模式;充分考虑农民的认知;强化和重构认知图式;增加主体认知机会;结合传统文化进行制度设计;重视和加强农民的心理考察与建设;优化管理和监督机制;加强医德建设;加快制定新农合法律法规的进程。第六章是本文的结论部分。本文运用以认知为基础的制度变迁理论对农村合作医疗制度的分析得出如下结论:制度是认知的结果;制度变迁是认知调整的过程;制度变迁是一个渐进的过程;政府、社会大众在制度变迁中发挥着不同的作用;学习、历史传统与制度变迁关系密切、信仰、认知与制度存在着互动的关系。更多还原

【Abstract】 Rural cooperative medical institution concerns the level of rural population’s medical security and rural economy development and social stability.Rural cooperative medical institution rose in 1950- 1960 when rural cooperatives was in climax, it was a medical and sanitarian safeguard institution by which healthy crowd and ailing crowd helped or relieved each other in the range of villages, and it has made tremendous contribution to solve laggard visage of rural area lacking of doctors and medicine. Made brilliant of "Chinese Model"by "least input, most health output." But after 1980, cooperative medical institution 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 own’s 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 affceted the health of peasants and the progress of rural area. Nowadays, new cooperative medical institution is implementing in order to solve the problems of becoming poor caused by illness and returning poor caused by illness. This institution experience the setting up, development, climax and to fading and reconstruction then to innovation. But the process of the innovation is not smooth, full of twists and turns. In the process of institution change, except the change of the environment, the cognition of the people are changed, too.D.C.North point out that, in order to really understand the action of the people, we need Cognigive science, Economics, Political science, Law, Sociology and so on to analysis the institution and institutional change. The thesis used the institutional changed theory based on cognitive to discuss the subject’s cognition and actions. Make effort to discover the process, nature and path of the institutional evolution based on the research of the subject’s cognition. And look it as the critical point to understanding the performance of the institution. To discove the real cause of the process of the institutional change. Then to explain the cause and the process of the rural cooperative medical institution from a new perspective.The chapters of the thesis go as follows:First is the introduction of the thesis. In this part, we present the motivation for writing the thesis and the evaluative survey of relevant literatures.Chapter 1 is the relavite theories. In this chapter, at first, we present a survey toward Cognitive scicence, Study, Institutional change and then explain the reason of introduction of Cognitive scicence.Chapter 2 is about the appearance and development of the rural cooperative medical institution. At this period the rural cooperative medical institution experience the peasants experiment, media report, government recognition, leaders’ direction, government extending. This chapter analysis the reasaon of the appearance and development of the rural cooperative medical institution during this period from the perspective of the cognition. Belief is the intrinstic factor of the institutional change. After Mao’s individual belief became the social’s belief, the rural cooperative medical institution acquire good performance.Chapter 3 is the analysis of the fading and reconstruction of the rural cooperative medical institution. The changed preference of the government, the disapperance of the common benefits between the junior government and center government, the arousal self-awareness of the peasants, the descending of the medical morality cognition of rural doctors, which disaggregation the common shared mental models. And during the reconstruction of the system, both the cognition stagnancy and cognitive dependence path make the system into involution.Chapter 4 is about the implementing of the new rural cooperative medical institution which means the institution innovation. The appearance of the institution crisis drives the institution innovation. But the beginning implement of the new rural cooperative medical system is not smooth. Which caused by the government limited rationality, the peasants reasonable ignorance, peasants anticipation, the trust degree to the governmet and fixed medical establishment’s attitude. But accompany the cognition adjustment of the government and the adjustment action of the peasants, the new rural cooperative medical institution become to perfect. Then analysis the relationship between the cognitive model and system innovation.Chapter 5 put out the suggestions to the institution.Including:constructing the reasonable cognitive model, considering the farmers’ cognition, strengthen the cognitive schemata, supplying more cognitive opportunities to subjects, considering traditional culture when design the institution, emphasis the farmers’ mental, optimizing the management and supervising mechanism, strengthen medical ethics construction, accelerating to develop relative law.Chapter 6 is concluding remarks. The concluding chapter summarizes the main results of the thesis.The conclusions as follows: constitution is the result of cognition, the process of constitutional change is the process of the cognition adjusting, the process of constitutional change is a progressive, government and masses play different roles in constitutional change process, study and traditional culture have close relationship with constitutional change, belief, cognition and institution are interactive.更多还原