【作者】 金建强；

【导师】 卢祖洵； 夏再兴；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2009， 博士

【摘要】 研究目的本次研究旨在对全国乡镇卫生院临床医生、乡村医生队伍现状进行有重点的、系统的调查和定量、定性分析的基础上，根据国家已经制定的法律法规及政策，提出相关政策建议，为国家制定乡村医生和乡镇卫生院临床医生向执业(助理)医师过渡的政策措施提供科学、可靠的依据。研究方法本次研究采用定量研究为主，结合定性研究方法。主要包括(1)文献研究；(2)现场调查：采用分层整群抽样的方法抽取东、中、西部各2个省，每省抽取2个县进行现场问卷调查；(3)专题小组讨论：召集相关人员讨论乡村医生和乡镇卫生院临床服务人员向执业(助理)医师过渡的政策、存在的主要问题并提出建议；(4)访谈法：(5)政策分析方法：分析乡村医生执业过渡各项卫生及其他部门政策的时代背景、发展状况以及发展趋势以及产生的问题；(6)典型案例分析法；(7)统计学方法：主要应用描述性统计分析方法，对乡村医生的基本情况，以及执业考试意愿情况、考试情况等进行现况分析。研究结果1．项目县抽样基本情况：(1)农村基层卫生保健网络基本健全，基本能够覆盖每一个行政村。(2)基层卫生机构公有为主，公有性质的村卫生室占所有机构的75．37％。(3)农村基层卫生机构人力资源不充足。2．乡村医生利乡镇卫生院现场调查结果：(1)乡村医生和乡镇卫生院临床医生专业素质偏低、乡村医生年龄老化。(2)执业化程度较低。村医中取得执业(助理)医师资格证书的为375人，仅占9．13％。乡镇卫生院临床医生中尚有19．13％的人未取得执业(助理)医师资格证书。(3)农村基层卫生人员保障水平低下。乡村医生只有24．97％的人购买了养老保险，乡镇卫生院临床医生月平均收入为984．61元。(4)乡村医生和乡镇卫生院临床医生培训意愿较高，且希望得到政策照顾。(5)受调查人员普遍反应，执业医师资格考试是必须的，但考虑到农村基层卫生人员的现状，尤其是乡村医生的现状，必须对现有政策作相关调整，才能实现既定目标。3．乡村医生和乡镇卫生院临床医生向执业(助理)医师过渡的相关政策分析结果：(1)国家已经建立了乡村医生和乡镇卫生院临床医生向执业(助理)医师过渡政策和有关规定，但各地在落实上都遇到困难。(2)相关政策之间的冲突导致新的问题出现，主要体现在乡村医生中专学历教育现行政策和参加执业医师资格考试政策之间有冲突。(3)缺乏较完善的培训经费保障和减免方面的政策。(4)缺乏乡村医生报酬、养老等社会保障方面的政策，不利于执业化进程。(5)各地地方政府根据实际情况，也探索并制定了一些促进乡村医生执业过渡的政策。研究结论目前我国农村地区基层卫生人员仍然面临着“专业素质低下、资质难获取、养老靠自己、收入无保障”的尴尬处境，要实现政策规定的目标，存在较大的困难。具体有(1)乡村两级基层卫生人员队伍现状影响执业化进程。(2)执业化进程进度缓慢、任重道远。(3)学历水平偏低是向执业(助理)医师过渡的主要难点。(4)相关政策之间的冲突导致新的问题出现，不利于执业化。(5)医师资格考试的方式和内容与农村实际不相符合。(6)保障水平低影响农村基层卫生人员稳定性。(7)应当适时建立乡村医生的养老保险体系。(8)希望获得有扶持性的专门培训，并建立长效机制。政策与建议(一)制定并完善医师执业资格考试相关政策。(二)按分类指导的原则制定相应的政策。(三)设立农村全科医学专业。(四)健全完善农村卫生人才队伍建设的长效机制。(五)逐步改善农村卫生人员的待遇。(六)由乡(镇)卫生院统一招聘乡村医生，推行乡村一体化管理。(七)逐步实现乡村医生向执业(助理)医师转化的目标。研究创新点1．在研究范围上，首次在全国范围内开展乡村医生和乡镇卫生院临床医生执业化抽样调查和研究，具有明显的创新性。2．本课题除为相关决策部门提供基础信息之外，还得出一些独特性的研究结论。如与乡镇卫生院临床医生相比，乡村医生对于培训的积极性更高，愿意承担的培训费用也要高些；我国执业化相关政策之间的冲突导致新问题出现等。更多还原

【Abstract】 ObjectiveThe aim of the paper was to study the current situation of the clinical doctors inthe township hospital and rural doctors in a systematic way with the focal points,toput forward the relevant policy recommendations based on the quantitative andqualitative analysis according to the national law,regulations and the relevantpolicies,and to provide the evidence for the policymaking on the transition fromrural doctors and clinical doctors in the township hospital to licensed (assistant)doctor.MethodsThe main methods concluded the quantitative analysis as well as the qualitativeanalysis.(1) Literature research.(2) The field investigation was done with speciallydesigned questionnaires in the six provinces,and the stratified clustering samplingwas applied to select two provinces respectively from the east,the middle and thewest part of China.(3)Focus group discussion was applied to discuss the policy,themain problems and the recommendations on the transition from rural doctors andclinical doctors to licensed (assistant) doctor by the leaders in the different relevantsectors of the government and the experts in the relevant fields.(4) The interview:the relevant leaders in the local health bureau,the head and two doctors of everytownship hospital,the two or a team of doctors in every village clinic were interviewed.(5) The policy analysis method:There were the analyses of the timebackground,the situation and trend of the development,the problems and the sectorpolicies on the transition from rural doctors to the licensed (assistant) doctors.(6)The typical case study.(7) The statistical analysis method:the descriptive study wasapplied to analyze the current basic situation of the rural doctor,the willingness tothe professional license examination,and the examination.Major Results1.The main information of the project counties were as follows.(1) The ruralhealth care net was basically sound because it could basically cover every village.(2)The rural health institutions at the basic level were mainly public owned and 75.37%of the village clinics were public owned.(3) The rural human personnel at the basiclevel was not sufficient.2.The results of field investigation of the doctors in the village clinics andtownship hospitals were as follows.(1) The doctors in the village clinics andtownship hospitals were not very qualified,the rural doctors faced the aging problem.(2) There was a low degree for the rural doctor to own the professional license:therewere 375 rural doctors who owned the professional license,which was only 9.13%of the total doctors in this investigation.(3) There was a low salary level for the ruralhealth personnel at the basic level:the majority of the investigated rural doctors hadthe low income,only 24.97% of whom purchased the aged insurance;theinvestigated clinical doctors in the township hospitals had average salary 984.61Yuan.(4) There was a high degree of willingness for the rural doctor and clinicaldoctors in the township hospitals to attend the professional training and they wishedto have the policy consideration of them.(5) The general reflection of theinvestigated personnel thought that the professional license examination wasnecessary,but the practical situation of the health personnel in the rural basic levelneeded to be taken into the consideration,therefore,the current policy on this aspectneeded to be adjusted in order to achieve the fixed goal in the long run.3.The results of the relevant policy on the transition fiom rural doctor andclinical doctor to licensed (assistant) doctor were found.(1) Although there were thedefinite policy and regulations on the transition from village doctor and clinicaldoctor in the township hospital to professional/assistant doctors with license,yet it’shard for the local health bureau to implement in the all rural areas.(2) The conflict ofthe different relevant policies led to the new problems.Such as the conflict betweenthe policy for the village doctor to receive the two-year college education and thepolicy for taking the professional license examination.(3) There was lack of soundpolicies to guarantee the training expenditure and its remittance.(4) There was lackof the social security policy for the rural doctors,such as the policy for their salaryand the aged insurance,etc.,and this impeded the process of professional licensedevelopment in the rural areas.(5) The local governments explored and made somepolicy to advance the transition from village doctor and clinical doctor to licensed(assistant) doctor according to their own practical situations,and these provided thetheoretical basis and experience support. Major ConclusionsAt present,the rural health personnel at the basic level still faced the embarrasssituation:there was a low quality of rural health personnel as a whole;it was hard forthem to obtain the professional license;there was no aged insurance for them,and itwas not guaranteed for them to have a stable income.The goal was hard to beachieved that the clinical doctors in the township hospital must have the professional/assistant license or higher certification,and other types of health personnel musthave the junior or higher professional license,and the majority of the rural doctormust have the professional/assistant license or higher certification.These were seenin the following aspects.(1) The process of obtaining the professional license wasimpeded by the low quality of the country health personnel in the current situation.(2) The process of having the professional licenses would be a long way with theslow change.(3) The main difficulty for the transition policy to be implemented wasthat the education level of the rural doctor was too low as a whole.(4) The conflictof the relevant policies on this aspect led to the new problems.(5) The contents ofthe professional license examination were not conformed to the practical healthsituation of the rural areas.(6) The stability of the rural health personnel wasaffected by the low income level.(7) There was a necessity to establish the agedinsurance system for the rural doctor.(8) The rural health personnel hoped to obtainthe supportive professional training and hoped that it could be a long-termedmechanism.Policy and SuggestionThere was a necessity to make the policy on the following aspects:1.To make and improve the relevant policy on the professional licenseexamination.2.To make the corresponding policy by the guiding principle of the classificationof rural health personnel.3.To establish a discipline of rural family medicine.4.To establish a long-termed mechanism of improving the quality of rural healthpersonnel.5.To improve the treatment of rural health personnel gradually6.To spread the integration management of township and village healthinstitutions by the employment of doctors by the township hospitals unified with thevillage clinics7.To gradually realize the goal of the transformation of rural doctor to thelicensed (assistant) doctor.Innovation1.It was the first time to do the sampling investigation and study of the ruraldoctors and the clinical doctors in the township hospitals on the professionallicense in the rural areas.2.There were some special conclusions besides providing the basic information for the policymaking of the government,such as:(1) Compared withthe clinical doctor in the township hospital,the village doctor had more activeattitudes towards the professional training and was more willing to bear morehigher expenditure for it.(2) The conflict of the different relevant policy on theprofessional license led to the new problems,etc.更多还原