【作者】 李晓敏；

【导师】 李崇光； 丁士军；

【作者基本信息】 华中农业大学 ， 农业经济管理， 2009， 博士

【摘要】 中国正在经历深刻的经济发展和社会转型。伴随着社会经济的发展与转型,医疗费用在近些年呈现出快速增长的趋势,广大民众的“看病难、看病贵”的问题也日益凸显出来。《中国发展报告20079指出,我国农村的贫困人口数存在较大的低估,贫困不仅仅只是“吃不饱饭”的生存贫困状态,还应涉及医疗和教育等方面。在我国农村大部分地区尤其是贫困地区,疾病尤其是大病已成为一大致贫诱因。鉴于农村地区存在着“看病难、看病贵”和“因贫致病,因疾返贫”等问题,有必要对农村医疗服务体制进行深层次改革。然而,长期以来,我国医疗服务的发展主要集中在“供给”环节,较少关注“需求”环节。国内关于农村医疗服务需求与利用的研究多以单个的个人为研究对象,较少关注农户这一微观经济单元。在我国农村,农户户内成员的行为在很大程度上受着农户作为一个整体的经济和社会特征影响和制约。因此,从农户这一需求主体来考察我国农村贫困地区的医疗服务需求与利用特征,不仅有利于提高农村医疗体制改革的针对性,而且对于改变农村地区“因贫致病,因病致贫”现象也具有重要的现实意义。基于对国家级重点贫困县和扶贫开发工作重点县-湖北省红安县的实地调查,本研究对农村贫困地区农户健康状况及特征、农户医疗服务需求状况和农户医疗服务需求的影响因素进行了分析,并对农户医疗服务利用的状况和差异性进行了考察,据此归纳出农户医疗服务利用的整体特征以及个体特征,继而探讨了影响农户医疗服务利用的主要因素,以期为我国农村贫困地区医疗服务体制改革的深化提供参考和依据。论文的研究内容主要包括:(1)调查地区农户健康状况及健康状况公平性。通过对调查地区农户自评健康状况、两周内患病状况以及大病患病状况进行考察,引入Allison和Foster的公平性测量方法,对农户自评健康状况这一指标的公平性进行度量。(2)农户的医疗服务需求状况以及影响农户医疗服务需求的因素。以农户为基本分析单位,对调查地区农户的医疗服务需求状况进行考察,并分别建立影响农户医疗服务需求决策的二项Logistic模型和多分类有序因变量回归模型(Ordinalregression),对影响农户医疗服务需求的因素进行分析,并得出相应结论。(3)农户的医疗服务利用状况和特征。从农户和个体成员两个层面对农村医疗服务利用状况及特征进行分析。在农户层面,依托定性的案例对农户户内医疗服务利用角色差异进行分析;在个体层面,从两周患病和年内大病患病两个方面入手,对处于不同经济状况患病人群的治疗方式选择、未治疗原因、门诊服务利用状况、住院服务利用状况以及门诊和住院费用负担等进行考察,并进一步总结农户医疗服务利用的个体特征。(4)农户成员的大病医疗服务利用的影响因素分析。通过对影响医疗服务利用的因素进行梳理,从定量和定性两个方面考察农户成员“大病”医疗服务利用的影响因素。在定量分析方面,利用“四步模型”分析方法分别建立大病门诊就诊概率Logistic模型、大病门诊就诊费用对数线性模型、大病住院概率Logistic模型、大病住院费用对数线性模型,同时建立住院单位选择影响因素的Logistic模型,对影响农户成员大病医疗服务利用的各项因素进行系统分析。在此基础上,将大病医疗服务利用的影响因素与全国第三次卫生服务调查报告中的医疗服务利用影响因素进行比较,以期为研究者未来研究方向提供一些可供参考的思路。在定性分析方面,本研究主要通过农户和个人的案例和评述等形式对定量分析的结论进行佐证,并对一些难以定量的、但对农户医疗服务有着重要影响的因素如社会关系网络、信息、健康意识、医疗服务提供者的诱导性行为等进行分析。(5)我国农村贫困地区医疗体制改革的政策建议。通过对贫困地区农户的健康状况、医疗服务需求状况及影响因素、医疗服务利用状况及影响因素的分析,本研究有以下发现:(1)农户健康状况分布呈现非公平性特征。健康状况分布的非公平性在不同经济状况的农户之间逐步拉大,尤其在富人和穷人之间更为突出。处于经济状况弱势的贫困农户,在健康状况上仍体现着同经济状况类似的弱势地位。(2)慢性病已上升为农村地区的主要疾病类型,但农户对慢性病的治疗仍缺乏主动。慢性病的大病患者在就诊概率、次均门诊费用、住院概率上比非慢性病大病患者的相应水平要低。(3)因疾病严重程度的不同,患病农户治疗方式选择存在较大差异。因疾病严重程度的不同,农户对于常见病和大病的治疗方式选择是不同的。对于常见病,农户更倾向于选择非正式的治疗方式;而面对大病,农户在治疗方式选择上会更加理性和谨慎,更倾向于选择正式治疗方式。(4)基层医疗机构是农户主要的就诊场所,扮演着较为重要的角色。无论是两周患病就诊机构的选择,还是大病门诊就诊机构的选择,县级及以下基层医疗机构仍是广大农户成员就诊的首选地点。村卫生室扮演着维护农户基本健康保护者的角色,而县级医院则是农户面临大病威胁时的不二选择。(5)经济状况对农户的医疗服务需求和利用行为有较大的制约作用。在我国农村贫困地区,经济困难仍然是广大农户看不起病的一大重要原因,贫困人群较其他人群更易因经济困难而放弃治疗。经济状况越差的大病患者,其就诊概率、次均门诊费用及住院概率就越低。在就诊单位选择上,经济状况越差的大病患者,越倾向于选择级别越低的医疗机构。(6)农户医疗服务需求和利用呈现出与农户经济状况不相符的特征。无论是大病患者门诊就诊费用,抑或是大病住院费用,贫困农户较富裕农户和一般农户承担了相对较高的医疗费用,这与农户的经济状况是不相符的。(7)农村医疗保障制度的保障性作用比较有限,保障功能尚不齐全。整体来看,因受补偿方式、报销范围、报销比例以及报销手续等的影响,新型农村合作医疗项目对农户医疗服务需求与利用的保障作用还比较有限;而贫困大病医疗救助项目以及其他医疗保障项目(如商业医疗保险等)在农村地区的覆盖范围还较小,其对大病患者就诊选择的影响力也较小。论文可能的创新点在于:(1)区别于以往多数研究从患者个体的角度出发,本研究既从个体角度,又从农户层面对农村医疗服务需求与利用状况等进行分析,丰富了已有的从患者个体角度对农村医疗服务需求与利用的理解和知识体系。(2)本研究从三个层面定义“大病”,即门诊、住院和因经济困难不能就诊但疾病对家庭经济有重要影响三个层面,对“大病”医疗服务利用状况进行了详细考察,分析了农户对于常见病和“大病”的医疗服务利用的差异和特征,并将农户“大病”成员医疗服务利用的影响因素与全国第三次卫生服务调查的发现进行了比较,对农村医疗服务利用的影响因素分析的有关发现是对全国第三次卫生服务调查发现的补充。(3)在具体的研究手段上,引入Allison和Foster的公平性测量方法对农户自评健康状况这一指标的公平性进行考察,有助于建立更加合理完善的健康公平性的研究方法和手段,也使得本论文关于健康公平性的研究更加完善,研究结论更加科学合理。更多还原

【Abstract】 China is experiencing a profound economic development and social transition. With its scioeconomic, healthcare expense grows rapidly in recently years. Consequently, many prominent obstacles such as physical difficulties and high costs of getting medical treatment that people are confronted with have been gradually emerging. The "China Development Report 2007" demonstrates that the number of impoverished people in China has been seriously underestimated. Poverty is not only inadequate for food, but also for medical care and education. Illness, especially major illness, has become an important source of transient poverty in rural China. On the intractable issue of physical difficulties and high costs of getting medical treatment, and the prevalent phenomenon in farm households that impoverished by illness and return to poverty because of illness, reform in the medical care system is necessary. However, for a long time, development in the medical care in China has been greatly focusing on the supply side alone, and less attention has been paid on demand side. Moreover, existed researches on medical care demand and utilization in rural China have concerned more at individual (or patient) level, but neglected farm household as a whole (as an economic unit at microeconomic level) in rural China. To some extent, the behavior of farm household members is greatly influenced by household as a whole. Therefore, the study on medical care demand and utilization with farm household as the unit of analysis in poor areas China not only helps to put forward reasonable suggestions on policies aiming at medical care system reform, but also be of practical significance for alleviating the so-called "vicious cycle" in which poverty and ill-health may be mutually reinforced.Based on data from fieldwork in one state-designed poverty county, Hong’an, in Hubei province, the dissertation surveys into the health status of households, describes the characteristics and influence factors of households’ demand for medical care, researches utilization of households on medical service, summarizes characteristics of utilization on medical service from household level and individual level, and analyzes the main factors that affect the medical care utilization of households. Finally, alternative suggestions on policies aiming at the reform and development of medical care system are proposed.The dissertation includes seven chapters. Main research consists of five parts. Firstly, farm household health status and health equity have been studied. By conducting analysis from such three aspects as self-reported health status, two-week mobidity as well as occurrence of major illness, the dissertation adopts Allison & Foster Equity Method to evaluate health distribution equity of self-reported health status within farm households. Secondly, the paper investigates, from a household perspective, the demand for medical care in detail and influence factors affecting on households’ medical care demand. In this part, binary logistic regression model and ordinal regression model are established to explore the influence factors that affect medical care demand of households. Thirdly, the paper surveys into medical care utilization of farm households and sums up characteristics of medical care utilization from such two levels as household and individual. From household level, case study approach is applied to analyze the utilization differences within household members. Meanwhile, from individual level, it researches, from such two aspects as two-week mobidity and major illness, types of treatment measures, reasons for seeking no treatment, outpatient services utilization, inpatient services utilization and medical care expenses. Fourthly, by summing up the possible factors that may influence medical care utilization of farm households, the paper investigates main influence factors of major illness medical care utilization through qualitative and quantitative analysis research methods. During the process of quantitative analysis, the author adopts Four-part Model which is combined with the model of outpatients and the model of inpatients to establish Outpatient Visits Logistic Probability Model of major illness, Outpatient Expenditure Loglinear Model of major illness, Logistic Regression Model of major illness hospitalization probability, Loglinear Regression Models of major illness hospitalization expenditure, as well as Multinomial Logistic Regression Model on affecting the choice of inpatient care providers, so as to comprehensively investigate determinants of medical care utilization of farm households, based on which the results from analysis of influence factors on medical care utilization are used to compare with relative findings of Report of National Health Services Survey in 2003 .While applying qualitative analysis method, by means of case study, the author explores other factors which are not analyzed in quantitative analysis, such as social network, information, health awareness and induced behavior from medical care providers, which have great impact on medical care utilization of farm households as well. Lastly, the paper puts forward countermeasures on deepening reform of medical care system in poor areas China.Through analysis of health status, medical care demand and medical care utilization in poor areas of China, the dissertation achieves such key conclusions as follow: (1) health distribution inequity exists in farm households of different economic situation. The worse farm households’ economic situation is, the wider health distribution inequity gap becomes, especially between the rich and the poor. Farm households in poor economic condition embody the same disadvantage position in health distribution as that in economic condition. However, the well-off farm households embody the same strong position in health distribution as that in economic condition. (2) When suffering chronic diseases which have been increasingly prevailing in rural China, household members tend negative attitudes toward treatment. Fewer services were used by patients with chronic diseases than those without. (3) Due to the severity of the illness that household member suffers, the types of treatment measures that farm household members receiving are quite different. When confronted with common diseases, farm household members tend to take informal treatment; while with major illness, farm household members would be more rational and cautious, and likely to receive formal treatment. (4) As the main medical place from which farm household members seek treatment, primary medical institutions play very important roles in poor areas China. In both two-week illness and major illness treatment, medical institutions at county level and below were regarded as the first choice place where household members get treatment, among which, village climcs act as the basic health care protector of household members and county level institutions are the alternative choice of household members when threatened by major illness. (5) Economic situation has great influence on medical care demand and utilization. In poor areas China, economic difficulty is still the main reason that household members can’t afford to get treatment when fall ill, especially for the poor. Fewer services were used by the household members in poor economic condition than those rich, when confronted with major illness. Likewise, on choosing medical care providers, the worse the economic situation is, the lower medical institutions level that household members choose. (6) Demand and utilization for medical care of household members partly embody the specific characteristic which is not commensurate with their economic situation. As far as inpatient utilization and outpatient utilization are concerned, the medical expense paid by the poor is much higher than that of the rich. (7) The insurance function of rural medical security system is still limited. Hindered by such aspects as the procedure of reimbursement, the scope of reimbursement and the proportion of costs reimbursed, new rural cooperative medical system has restricting effect on medical care demand and utilization of households. Furthermore, medical aid and commercial medical insurance in rural China, with narrow coverage, also make minimal impact on treatment seeking behavior relatively.The dissertation explores some probable innovation in the following dimensions:Firstly, by investigating into health status and health inequity of farm household, from such two perspectives as household and individual, the dissertation analyzes health care demand and health care utilization, and explores the factors that influence medical care demand and uyilization of households.In addition, with case study approach, it finds out some characteristics of medical care utilization within household members. This helps make up, in part, for theoretical and practical research limitations in medical care demand and medical care utilization.Secondly, elaborating on major illness, from such three dimensions as inpatient treatment, outpatient treatment and no treatment, which has significant impact on farm household economy, the dissertation first investigates medical care utilization of "major illness". By conducting the analysis of medical care utilization on both two-week illness and major illness, it finds out differences in medical care utilization between them. Moreover, the dissertation pays more attention to the analysis of influence factors affecting on major illness medical care utilization, of which, the results would be a current suppplement to the relative findings of Report of National Health Services Survey in 2003. This may provide some considerable references for future research and may point out where future research should go.Thirdly, by adopting Allison & Foster Equity Method which is distinct from other research mehods such as Gini coefficient and Theil’s entropy index, this study evaluates health distribution equity of self-reported health status within farm households, which would round out the research approaches to health equalities measurement.更多还原