【作者】 刘雅静；

【导师】 周向军；

【作者基本信息】 山东大学 ， 马克思主义基本原理， 2009， 博士

【摘要】 本文主要是从多维视角分析和研究新型农村合作医疗制度的发展问题。新型农村合作医疗制度是由政府组织、引导和支持,农民自愿参加,个人、集体和政府多方筹资,以大病统筹为主的农民医疗互助共济制度,目的是为了解决农民的就医问题,减轻农民因疾病带来的经济负担,提高农民的健康水平。对新型农村合作医疗制度的健康、可持续发展问题进行研究具有十分重要的理论和现实意义。这不仅可以进一步加深人们对新型农村合作医疗制度可持续发展重要性的认识,而且有助于我们从理论上进一步明确新型农村合作医疗制度实现可持续发展的条件和运行机理,也有助于我们从制度上进一步揭示新型农村合作医疗制度未来的发展趋势和创新方向。目前,国内外学术界对新型农村合作医疗制度的研究主要集中在以下几个方面:关于新型农村合作医疗制度的筹资机制研究;关于新型农村合作医疗制度的补偿机制研究;关于政府在新型农村合作医疗制度建立与完善中的职责研究;关于新型农村合作医疗制度试点的实践模式研究;关于新型农村合作医疗制度实施效果的评价指标研究等。这些研究成果,为进一步深入、系统的研究积累了丰富的经验,打下了良好的基础。但是,如同我国新型农村合作医疗制度在实践上还存在着很多欠缺和不足一样,对新型农村合作医疗制度理论上的研究也还存在着一些缺憾。如在已有的研究中,对新型农村合作医疗制度本身的研究较多,但对新型农村合作医疗制度赖以存在的社会环境研究得较少;对政府在新型农村合作医疗制度建设和完善中的职责和作用研究得较多,但对农民这一主体在新型农村合作医疗制度建设和完善中的参与机制和参与作用研究得较少;对如何加强对合作医疗需方的管理研究较多,但对如何加强对合作医疗供方的有效管理研究得较少;特别是从制度设计、主体职责、外部环境等多维视角全面分析和探讨新型农村合作医疗制度可持续发展的理论和实证研究还比较缺乏。本文在学术界已有研究成果的基础上,对当代中国新型农村合作医疗制度的发展问题进行了全面的多视角的分析和研究。具体的研究思路是:从全面建设小康社会和大力推进社会主义新农村建设以及构建社会主义和谐社会的大背景出发,以马克思主义经典作家的社会保障理论和合作经济理论、中国共产党有关农村医疗保障的相关理论、西方相关社会保障理论为依据,采用规范分析与实证分析相结合、定性分析与定量分析相结合等多种研究方法,从历史与现实、理论与实践、必要性和可行性、制度与环境、主体功能与主体行为等多重视角,对实现我国新型农村合作医疗制度可持续发展的必要性、可行性及现实路径进行全方位、多领域的分析和研究,目的就是探寻能确保我国新型农村合作医疗制度实现可持续发展的有效对策和思路,以最终实现新型农村合作医疗制度的健康、可持续发展。本文的创新之处主要体现在:一是从理论上对建立和发展我国新型农村合作医疗制度的必要性和可行性作了全方位、多视角的分析,揭示了建立和发展我国新型农村合作医疗制度的理论依据、现实依据和可行条件。二是基于调研获取的大量可靠的统计资料和数据,对我国新型农村合作医疗的运行状况作了较为详尽、系统地描述,并对这一制度存在的问题和成绩进行了客观、全面地整理和分析;三是从制度设计、主体职责、外部环境等不同视角,就如何顺利推进我国新型农村合作医疗制度的健康、可持续发展问题提出了一些自己的观点和主张。新型农村合作医疗制度是在传统农村合作医疗制度的基础上演变而来的。回顾与反思我国传统农村合作医疗制度的曲折发展历程,可以使我们得到很多有益的经验和启示。20世纪60-70年代是传统农村合作医疗制度在我国农村的兴盛时期,兴盛的原因主要在于:政府强有力的行政性推动使农村合作医疗的迅速发展获得了强大的外力;“政社合一”的人民公社体制为农村合作医疗的迅速发展提供了必要的体制保障;低成本运营的医疗服务供给体系为农村合作医疗的蓬勃发展提供了重要的制度运行基础;农民群众的积极参与为农村合作医疗的迅速发展提供了必要的群众基础。20世纪80-90年代我国传统农村合作医疗大面积解体,而且恢复与重建困难。造成这种状况的原因主要在于:政府职能缺位制约了农村合作医疗的恢复与发展;集体经济组织力量弱化直接削弱了农村合作医疗的经济和组织基础;传统农村合作医疗自身的制度缺陷使其难以适应新的挑战;农民参与意愿不强使合作医疗的发展在很大程度上失去了群众基础;医疗服务过度市场化改革导致的医疗费用不断上涨使传统农村合作医疗难以为继。通过对我国传统农村合作医疗制度曲折发展历程的历史性回顾与反思,我们得出了三点结论:其一,完善的制度设计是确保合作医疗制度可持续发展的基础性保障;其二,适宜的制度环境是确保合作医疗制度可持续发展的必要条件;其三,政府的积极干预和公共支持是确保合作医疗制度可持续发展的关键。建立和发展我国新型农村合作医疗制度不仅是必要的,而且是可行的。其必要性可以从理论依据和现实依据两个方面分析。理论依据主要包括:马克思主义经典作家关于社会保障理论和合作经济理论的相关论述为其提供了重要的理论指导;以毛泽东、邓小平、江泽民、胡锦涛等为代表的中国共产党人所提出的关于农村医疗卫生事业发展思想为其提供了直接的理论依据;西方国家有关学者关于风险理论、反贫困理论、福利经济理论、人力资本理论、国家干预理论的论述从不同方面为其提供了有益的理论借鉴。现实依据主要包括:建立和发展新型农村合作医疗制度是维护和保障公民健康权的内在要求;是全面建设小康社会的必然要求;是顺利推进社会主义新农村建设的重要保证;是建设社会主义和谐社会的重要措施。建立和发展新型农村合作医疗制度的可行条件是:经济的快速发展和经济实力的不断增强为其提供了必要的经济基础;党和政府对“三农”问题的高度重视为其提供了强有力的政治保证;全社会对“三农”问题的高度关注为其提供了十分有利的社会条件;我国农村医疗卫生事业的发展为其提供了必要的人才条件和组织条件。建立和发展新型农村合作医疗制度的必要性和可行性的统一,昭示了这一制度可持续发展的历史必然性。建立和发展新型农村合作医疗制度是一项复杂而又艰巨的社会系统工程,不可能一蹴而就,必须先行试点,取得经验后再逐步推广。2003年以来,我国新型农村合作医疗制度的试点进展顺利,成效明显,为实现新型农村合作医疗制度的健康、可持续发展积累了必要的经验,打下了良好的基础。其一,新型农村合作医疗的制度框架和运行机制已经基本形成,各级政府有关新型农村合作医疗的管理制度日趋完善,在组织管理上也已经形成了自上而下、政府领导、卫生部门主管、相关部门协调配合、经办机构进行日常业务运作的组织体系。其二,农民参与新型农村合作医疗的热情不断提高,新型农村合作医疗覆盖面不断扩大,农民的医疗负担有所减轻,农民“因病致贫、因病返贫”问题有所缓解。其三,农村定点医疗机构的服务条件有所改善,服务质量和水平有所提高,农村定点医疗机构开始走向良性发展的轨道。现行新型农村合作医疗制度在制度设计及制度运行等方面尚存在一些缺陷和问题。其一,制度本身还存在着一些不完善的地方。如在筹资环节,还存在着筹资水平低、筹资渠道不畅、筹资不公平等问题;在补偿环节,还存在着补偿受益面窄、补偿程度低、报销程序繁琐等问题;在基金监管环节,还存在着基金被挤占、被挪用、被贪污的监管漏洞。其二,在制度运行过程中还存在着主体功能作用发挥不充分、主体行为不规范等问题。如政府在推动新型农村合作医疗制度的过程中还存在着诸如宣传不到位、监管不力、立法滞后等问题;农民还存在着参合意愿不强以及参合过程中的“逆向选择”和“道德风险”等问题;定点医疗机构还存在着诱导农民医疗需求、诊疗不规范、服务能力低下等问题。其三,在外部环境方面还存在着种种不利于甚至制约新型农村合作医疗制度可持续发展的因素。这些问题如不能及时得到有效地解决,将可能降低这项制度的保障效力或者导致制度目标的偏离,阻碍新型农村合作医疗制度的健康运行和可持续发展。要实现新型农村合作医疗制度的健康、可持续发展,不仅要解决好新型农村合作医疗制度的科学设计问题,而且必须充分发挥各主体的职能作用并不断规范各主体的行为,同时还必须不断为新型农村合作医疗制度的健康发展创造适宜的外部环境。其一,必须解决好新型农村合作医疗制度本身的科学设计和不断完善问题。要在详细调查研究的基础上,根据有关科学原理,不断创新和完善新型农村合作医疗制度的筹资机制和补偿机制。其二,必须把政府、参合农民、定点医疗机构三方主体的积极性充分调动起来,有效发挥三方主体的功能和作用。一是政府必须吸取传统农村合作医疗兴衰的经验教训,借鉴国外好的做法,切实承担起制度设计、宣传发动、资金投入、组织协调、管理监督、卫生服务、行政立法等多项重要职能。二是必须充分重视并充分发挥农民在新型合作医疗制度中的主体地位和作用,千方百计调动广大农民群众参与的积极性,同时,还必须采取有效措施尽可能地减少或避免参合农民的“逆向选择”和“道德风险”。三是必须加强对新型农村合作医疗定点机构的管理和监督,强化其医疗服务意识,规范其医疗服务行为,确保其为参合农民提供规范、质优、价廉的医疗服务。其三,必须不断优化新型农村合作医疗制度发展的外部环境。如千方百计增加农民收入、深化农村药品市场改革、加强农村医疗卫生服务体系建设、完善农村医疗救助制度等。制度的完善是一个过程,需要与时俱进。随着社会经济的不断发展,新型农村合作医疗制度面临的外部环境在不断变化,同时,随着新型农村合作医疗制度的不断推行,制度本身面临的新问题也会不断出现,解决问题的方案也必须随实践的发展而不断调整和完善。因此,对新型农村合作医疗制度可持续发展问题的研究本身也应该具有可持续性。更多还原

【Abstract】 The present dissertation aims to discuss issues on China’s new rural cooperative medical care system development from multiple perspectives. The new system is strongly featured by joint support and relief with combined commitments of government organization, direction and support, farmers’ voluntary participation, pool of funds by parties of individuals, collectives, and governments, so as to enable farmers to access medical care when in need, lessen their financial burden, and improve their level of health. The nature of the new system itself as well as in-depth discussions about theoretical foundations and explorations about the path to healthy and sustainable development of the new system suggests the practical and theoretical significance of the present study. The findings will help strengthen the awareness of the importance of the sustainable development of the new system, identify the conditions and operation mechanism for the ultimate goal to materialize, and yield institutional insights for how and in what new directions the new system will develop.The current academic research in the field of China’s current new rural cooperative medical care system has developed mainly along the following lines. They include its fund raising mechanism, compensation mechanism, government’s responsibility for its construction and amelioration, practiced models of its experimental areas, performance assessment indictors of its implementation, etc. Though these findings have laid foundations and opened paths for further and systematic research, there are some gaps needed to be further explored and improved in both practice and theory respects. Though there has been a relatively large body of research on the new system itself, government’s responsibility for its construction and amelioration and their role, recipients management enhancement, little has been done with societal environment for the new system to be grounded in, farmer participation mechanism and function for its construction and amelioration, effective supplier management enhancement. Significant remains lack of systematic discussion about the new system’s sustainable development issues from a multi-dimensional perspective and of empirical study as well. The present study aims to open such a discussion and fill the gap. Inspired by the current research literature, the present study begins with an introduction to its background, i.e. the construction of a full-scale well-off society and a socialist new village through vigorous efforts and a socialist harmonious society, and theoretically grounded on social security and cooperative economy by Marxist classic writers, relevant rural medical care security by the Communist Party of China, and relevant western social security. Its research methodology is characteristically multi-dimensional, inclusive of a combination of normative and empirical approaches, and quantitative and qualitative approaches, and perspectives of history and reality, theory and practice, necessity and feasibility, system and environment, participating agent function and conduct, etc. A holistic, multi-dimensional, multi-layered study is conducted to examine the necessity, feasibility and path of the sustainable development of the new rural cooperative medical care system. Its objective is to explore effective counter-measures and solutions for the new system to healthily develop and sustain. The main contributions of the present study lie in the following three respects. First, it opens a holistic and multi-dimensional discussion about the necessity and feasibility of the new rural cooperative medical care system construction and amelioration from a perspective of theoretical foundations, thereby revealing theoretical and practical support, and facilitating conditions. Second, it provides a relatively thorough, and systematic description of the contemporary China new rural cooperative medical care system operation based on a large collection of reliable statistics and data and an objective, and sufficient categorization and analysis of problems and achievements concerning the new system. Third, it concludes with some ideas and proposals for how to promote the healthy and sustainable development of the new system from perspectives such as system design, agent accountability, and external environment.The new system evolves from the traditional rural cooperative medical system. To fully understand and analyze the new rural cooperative medical system requires a historical review of China’s traditional rural cooperative medical system. Explanatory reasons for success or failure in the course of China’s traditional rural cooperative medical system lay foundations for analyzing problems in the new rural cooperative medical system and provide insights on its sustainable development. A review and reflection of China’s traditional rural cooperative medical system has yielded three findings. First, a comprehensive system is designed to ensure the foundation of sustainable development in the cooperative medical system. Despite an important role in protecting farmers the health, The rural cooperative medical system design was flawed and insufficient because of a limited fund coverage, weak capacity to shelter from risks, lack of effective expense restraint mechanism for farmers, and effective fund management and supervision mechanism, a focus on prevention but a low level of protection. These weaknesses were closely tied with the traditional planned economic system for its operating environment. All in-built deficiencies determine the unsustainable development of the system. Second, appropriate environment is required for a system to operate soundly. Even the same system design will have varied outcome if operating in different environments. From 1960s through 1970s, the traditional rural cooperative medical system functioned well because its arrangement was suitable for its operating environment. From the 1980s through the 1990s, the widespread breakdown and subsequent recovery and reconstruction of tradition rural cooperative medical system were attributable to great changes in the socio-economic environment. The environment was no longer suitable for the traditional system. Third, the government’s active intervention and public support was key to sustainable cooperative medical system development.To develop and ameliorate a new rural cooperative medical system is not only necessary but also practical. The necessity can be understood in terms of both theory and practice. On the one hand, propositions related to social security and cooperative economy theories by Marxist classic experts provide important theoretical foundations for the new rural medical system. Guidelines for the rural medical care and hygiene cause by communist party leaders such as Mao Zedong, Deng Xiaoping, Jiang Zemin, Hu Jintao, constitute the direct theoretical source of the new system. Other theoretical sources include propositions and implications of western risk theory, counter-poverty theory, welfare economic theory, human capital theory, government intervention theory. On the other hand, to construct and ameliorate the new system is an inherent requirement by defending and warranting citizens’ health right, an eventuality of constructing a comprehensive well-off society, an important guarantee by smoothly promoting a new socialist village, and an important move of building a socialist treatment standard and improve their service capacity. Moreover, external environment also constrains the new system’s sustainable development. Significant is the constraint of farmers’ low income, particularly in poverty-stricken areas. These problems, if not managed and solved duly and effectively, may reduce its security effect or lead in a wrong direction, thereby hindering its healthy operation and sustainable development.The healthy and sustainable development of the new rural cooperative medical system requires a proper scientific system design, continual efforts in mobilizing parties concerned to their full play and in regulating their conduct, and efforts in improving favorable external environment. First, it is imperative to improve and invent the fund-raising mechanism and compensation mechanism of the new system based on thorough survey and research and guided by relevant scientific principles so as to continually ameliorate the system design. Second, it is urgent to marshal the commitment by three main parties concerned in the new system, i.e. government, participating farmers, and designated medical institutions, and bring their function and role to full play: 1) the government must learn from the history of the traditional rural medical system boom and collapse, and practices outside China’s mainland as well, and undertake full responsibility of system design, propaganda and launch, pumping funds, organizational coordination, administrative supervision, health service, administrative legislation, among other functions; 2) it is crucial to stimulate farmers’ participation by all means and take measures to reduce the "adverse selection" and "moral hazard" problem to a minimum extent; and 3) it is necessary to reinforce management and supervision of designated medical institutions, and raise their service awareness, regulate their service conduct, so as to provide participating farmers with standard, high-quality, and affordable medical service. Third, it is a must to continually improve the external environment favorable to the new system’s healthy and sustainable development. Vigorous efforts must be taken to increase farmers’ income, further the rural drug market reform and the rural medical and health service system construction, and refine the rural medical relief and support system, etc.As an evolving process, the current new system involves continual cultivation and refinement. The economic growth in the past few decades and beyond have treatment standard and improve their service capacity. Moreover, external environment also constrains the new system’s sustainable development. Significant is the constraint of farmers’ low income, particularly in poverty-stricken areas. These problems, if not managed and solved duly and effectively, may reduce its security effect or lead in a wrong direction, thereby hindering its healthy operation and sustainable development.The healthy and sustainable development of the new rural cooperative medical system requires a proper scientific system design, continual efforts in mobilizing parties concerned to their full play and in regulating their conduct, and efforts in improving favorable external environment. First, it is imperative to improve and invent the fund-raising mechanism and compensation mechanism of the new system based on thorough survey and research and guided by relevant scientific principles so as to continually ameliorate the system design. Second, it is urgent to marshal the commitment by three main parties concerned in the new system, i.e. government, participating farmers, and designated medical institutions, and bring their function and role to full play: 1) the government must learn from the history of the traditional rural medical system boom and collapse, and practices outside China’s mainland as well, and undertake full responsibility of system design, propaganda and launch, pumping funds, organizational coordination, administrative supervision, health service, administrative legislation, among other functions; 2) it is crucial to stimulate farmers’ participation by all means and take measures to reduce the "adverse selection" and "moral hazard" problem to a minimum extent; and 3) it is necessary to reinforce management and supervision of designated medical institutions, and raise their service awareness, regulate their service conduct, so as to provide participating farmers with standard, high-quality, and affordable medical service. Third, it is a must to continually improve the external environment favorable to the new system’s healthy and sustainable development. Vigorous efforts must be taken to increase farmers’ income, further the rural drug market reform and the rural medical and health service system construction, and refine the rural medical relief and support system, etc.As an evolving process, the current new system involves continual cultivation and refinement. The economic growth in the past few decades and beyond have impacted and will impact the external environment where the new rural cooperative medical system operates. New issues will emerge along with the on-going implementation and require solutions different from conventional ones. In return, they call for empirical research on sustainable development issues of the new rural cooperative medical system. These lines of considerations not only give support for the significance and value of the present study but also highlight the need to continue the present line of study in the future.更多还原