【作者】 贾清萍；

【导师】 甘筱青；

【作者基本信息】 南昌大学 ， 管理科学与工程， 2010， 博士

【摘要】 农村医疗是目前中国医疗问题中最薄弱也最难以解决的部分,它关系到农村社会的稳定与发展,关系到农民的生活健康,关系到“三农”问题的解决,对新农村建设、农村医疗体制改革有重要的影响。我国近20年的前期医疗卫生体制改革走市场化道路,尽管过去的医疗改革确实解决了改革开放初期的缺医少药的情况,但也促使医院宾馆化的现象产生,医疗服务的公平性下降和卫生投入的宏观效率低下,违背了医疗卫生事业作为公共产品性质的基本原则和规律,导致“看病贵、看病难”问题严重,产生了饮鸩止渴问题。现中国新的医疗卫生体制改革已展开,农村医疗卫生体制改革同步进行。国家进行了一系列宏观卫生政策的调整,改革力度之大受到全世界瞩目,但改革中又出现新的问题,表现出典型的外部政策对系统行为干预无效的系统性症状。需要多方法学进一步分析前期医疗卫生体制改革产生问题的原因,为新的医疗卫生体制改革提供政策依据。需要多方法学进一步论证新的医疗卫生体制改革中出台的新对策的正确性,防止出现新的饮鸩止渴、舍本逐末、恶性竞争等问题。中国医疗卫生服务系统是一个复杂系统,有很多问题待用系统科学的方法进行研究。基于这些背景,用系统动力学方法和运筹学等方法结合研究农村医疗服务供应链系统问题具有重要意义。本文首先在梳理国内外关于农村医疗及其服务供应链研究相关成果的基础上,对农村医疗卫生体制改革进行深入调查,构建农村医疗服务供应链结构模式。通过对萍乡市五个县级综合医院,包括芦溪县人民医院、上栗县人民医院、莲花县人民医院、湘东区人民医院、安源区人民医院的深入调研；对江西省卫生厅的专访,对农村医疗卫生体制改革进行调查；对下埠镇农村居民的深度访谈,获取第一手调查资料和数据,并结合供应链的理论,构建了由政府、医疗产品供应商、农村医院、农村居民为主体的农村医疗服务供应链结构模式。第二,基于调研,结合供应链结构模式,利用一元回归、多元回归、Logistic回归分析方法分别构建了农村医疗服务供应链不同环节主体行为影响因素的回归模型,进行影响因素分析。并通过变量筛选,找出了影响农村医疗服务供应链发展的参加合作医疗人数、县级医院科室、医务人员数、医疗技术水平、医疗设备、医疗价格、医疗保障等核心变量,并对各自的影响程度进行了分析,为建模及仿真的变量选择与方程建立作铺垫。第三,基于农村医疗服务供应链的模式,从整体医改出发,利用复杂系统理论,分别对政府环节、医疗产品供应商环节、医院环节、农村患者环节中存在的问题进行了反馈基模分析。构建了24个涉及农村医疗服务供应链发展的问题基模和从整体出发管理对策基模。通过对基模的分析,找出制约农村医疗服务供应链发展的因素,并提出了从整体出发完善农村医疗服务供应链运行机制的八条管理对策,其中包括(1)进一步完善新型农村合作医疗制度建设,(2)加快农村医院改革,(3)进一步加大政府对农村医院的投入等。从整体出发对农村医疗服务供应链系统问题进行了研究。第四,在整体医改基模分析的基础上,组建系统动力学的核心变量数据、入树、枝向量反馈环计算、管理对策、仿真五步分析法,创新性地基于反馈环集合结构和从作用力角度出发,提出且仿真论证了对新型农村合作医疗制度建设子系统产生经济支撑力、内生成力、吸引力、动力的四大管理子对策的正确性。论文通过核心变量数据系构建基模,建立新型农村合作医疗系统仿真实验入树流图模型,基于反馈环集合与反馈环特性从作用力的角度提出了发展新型农村合作医疗子系统子对策并进行仿真实验,定量揭示新型农村合作医疗对策实施效果。创新性地提出了消除农村医疗服务供应链负反馈环制约的原理：通过政府、农村医院、农民、城市医院、药品产供销各自责任、目标和利益的实现,达到实现消除农村医疗服务供应链负反馈环制约的总目标。通过对新型农村合作医疗运行效应作用力分析,得出了新型农村合作医疗系统运行产生的四大作用力,即经济支撑力、内生成力、吸引力、动力。针对这四个作用力,提出了新型农村合作医疗制度建设子系统发展的四大对策,即不断提高中央及地方政府补助比重,增强农村医疗卫生的经济支撑力；大幅增加参合农民,不断扩大覆盖面,增大农村医疗卫生发展的内生成力；不断提高医疗补偿人次和扩大受益面,增加农民主动投入农村医疗卫生体制改革的吸引力；加快新农合发展,增加医院、医药、公共卫生三个子系统实现各自目标责任的动力。第五,在整体医革基模分析的基础上,对加快农村医院改革子系统进行了深入研究,新建系统动力学的对策作用力因果链传递效应分析法,应用因果链传递效应进一步证明了前期医疗卫生体制改革产生“看病贵、看病难”的原因,又应用因果链传递效应证明了县级医院子系统综合发展六条子管理对策的正确性,而且采用流率基本入树作为调控参数,对对策的因果链传递效应证明的正确性进行了可靠性仿真分析。基于核心变量是系统的原子和因果链是系统的分子新思想,新建系统因果链传递效应分析法。基于深入调研的萍乡市五个县级发展的历史数据建立新核心变量集合,建立因果链序列,建立因果链的顶点度序列,由顶点度序列对因果链的链接力,产生县级医院服务供应链系统核心变量增长上限基模。基于增长上限基模因果链结构,首先应用因果链传递效应,证明和分析了中国前期医改中农村居民“看病贵、看病难”问题产生的原因。其次,应用因果链传递效应,证明了现行医改中基于消除县级医院医疗服务供应链系统负反馈环制约的原理提出的县级医院子系统发展六条子管理对策正确性,建立九棵流率基本入树,创新性地采用新农合流率基本入入树调控参数法,对对策的因果链传递效应证明的正确性进行了可靠性仿真分析。最后,基于仿真作用力因果链传递效应分析,提出了中国新农村医疗卫生体制改革的几点建议。(1)在新农合制度政策制订及实施中,各级政府和农民要注重发挥经济支撑力、内生成力、吸引力、动力的四种力量的作用,促进各作用力的不断增强,通过作用力使新农合不断深入发展。(2)在医疗卫生体制改革中,各级政府和管理人员要注重通过政府、医院、医药企业、农村和城市居民各自目标责任的实现,来实现医疗卫生体制改革制度的总目标,这是体制改革的原理,不执行此管理对策医改难以成功。(3)政府在新农合政策制订过程中,要注意控制农民的缴费数额。因为根据新型农村合作医疗反馈环效应分析得到,如果农民缴费高度增加,将会制约农民参合人数。(4)新农合对县级医院的门诊人次、住院人次、医务人员数等有正向影响,因此要进一步加强新农合政策实施力度,促进县级医院发展。(5)通过反馈仿真分析,证明了县级医院没有能力靠自身运转解决医疗设备、科室建设等资金问题,因此,还必须进一步加大政府对县级医院的建设投入。更多还原

【Abstract】 Medical problems in rural areas are the weakest and the most difficulty problem in health system reform in China. It has not only impact on the stability and development of rural society and the health lives of rural residents, but also hinder solving the "three agricultural problems". At the same time, it has an important influence on the construction of new countryside and rural medical system reform. In recently 20 years, the health system reform model in China is marketization. The previous health system reform has really solved the problem of deficiency of medical treatment, but also contributed to the phenomenon of luxury hospital. The decreased fairness of medical services access and the inefficiency of macro heath investment have contrary to the basic principles and laws that medical services is public goods, which result in the problem that expensive medical bills and difficult access to quality medical services for residents become serious, and then the phenomenon that drinking poison to quench thirst is generated. Nowadays, the new health system reform has performed, and the rural health system reform also has implemented simultaneously. A series of macro health reform policies which the worldwide people concerned are performed by government. But new problems in health reform have emerged, which showed that there exist a typical systemic symptoms that external policies have little effect on system behavioral interventions. So it is urgent to apply multiple methodologies to further analysis the cause of problem in previous health system reform to provide reference for the new health care reform, and to further demonstrate the correctness of policy in the new health system reform, and to prevent the generation of the new problems of drinking poison to quench thirst, concentrating on details but forget the main purpose or objective, and competating viciously. The medical and health services system in China is a complex system, there are a lot of problems need to study by scientific methods. Based on above problem, it is significant to study rural healthcare service supply chain by system dynamics methods.In the dissertation, firstly, rural healthcare service supply chain structure model is built by both reviewing the papers on rural healthcare and its service supply chain at home and abroad, and investigating in rural health system reform in China. the first-hand survey data and information of health care system reform are obtained by both investigating in five county hospitals in Pingxiang city, including Luxi County People’s Hospital, Shangli County People’s Hospital, Lianhua county People’s Hospital, Xiangdong District People’s Hospital and Anyuan District People’s Hospital, and interviewing with experts in health department of Jiangxi province and rural residents in Xiabu town. Based on theory of supply chain, rural healthcare service supply chain structure model is built, in which composed of governments, medical product suppliers, rural hospitals and rural residents.Secondly, based on research and structure model of supply chain, unitary regression analysis method, multiple regression analysis method and Logistic regression method are used to construct the regression model of influencing factors of behavior in different links of rural healthcare supply chain respectively. And we have obtain its core variable by variable selection of regression, which include in the number of participants in the new rural cooperative medical system, department in county hospital, medical staff, medical skills, medical equipment, medical prices, medical security and so on. And we have conduct analysis on their influence degree, which pave the way for the simulation of variable selection.Thirdly, based on the rural healthcare service supply chain structure model and theory of complex systems, the archetypes is built in the different links of the service supply chain, in which included government, medical products supplier, hospital, and rural patient link.24 archetypes are constructed and analyzed, a series of restrictive factors in rural healthcare service supply chain are founded. Eight management countermeasures are put forward, but the most important three management countermeasures as follows:(1) Further improving the new rural cooperative medical system. (2) Speeding up the reform of rural hospitals; (3) Increasing fund for rural hospitals by government.Fourthly, based on archetype analysis in the overall medical and health system reform, and the core variable data of system dynamics, the rate variable fundamental in-tree models, feedback loop branch vector determinant computation, management countermeasures, and the new in-tree-feedback-simulation-force five-step analysis method, according to the feedback set structure and in an innovatively perspective of force, the four management countermeasures are put forward and the correctness of them are proved. The four countermeasures come from the four force generated by the new rural medical cooperation system, which include the inner-generated-force, economic support force, attraction and motive force. By constructing the core variable base model, establishing simulation flow graph model of the new rural cooperative medical system and conducting simulation experiments, implemented effect of the new rural cooperative medical policy is revealed quantitatively. The negative feedback loop limited principle is put forward innovatively in this dissertation, that is, it is necessary to firstly realize the respective responsibilities, objectives and interests, including the government, rural hospitals, rural residents, city hospitals, pharmaceutical supply and production enterprise in order to achieve the overall objective of eradicating negative feedback loop constraints in rural medical services supply chain system. Four forces are generated in the operation processes of the new rural cooperative medical system, which include inner-generated-force, economic support force, attraction and motive force. And four countermeasures about the development of rural healthcare services supply chain are put forward based on the four forces. They are as follows:(1)subsidies proportion of health care in rise by central and local government to strengthen the economic support force for medical and health of peasant; (2)the participation peasant increased greatly, the coverage of participation continually expanded, which empower the inner-generated force for rural health care; (3)the increase of the numbers of medical compensation peasant and the expand of compensation benefit scope will strengthen the peasants’attractive to reform rural health system;(4) to speed up the development of the new rural cooperative medical system will strengthen the motivation to realize their goals for the four subsystems, include health insurance subsystem, hospital subsystem, medicine subsystem and public health subsystem.Fifthly, based on archetype analysis in the overall medical and health system reform, we have deeply research on the subsystem of rural hospital reform. A new system dynamics method that is causal chain transfer effect by countermeasure force is built, and be applied to prove the cause of expensive medical bills and difficult access to quality medical service for residents. The correctness of six management countermeasures of county hospital comprehensive development is proved. And we have innovatively set a rate variable basic in-tree as control parameter to simulate and prove the correctness of countermeasures by the new method of causal chain transfer effect by force.Based on the new ideas that core variables are atoms and causal chain is molecules in system, we have innovatively built a new systemic causal chain transfer effect by force method. According to the historic data from the deeply research on the five county hospital in Pingxiang city, a new set of core variables is built, and a causal chain sequence is established, and then a causal chain vertex degree sequence is built. A upper limit growth archetype which is composed of core variable in service delivery supply chain of county hospitals is built by the vertex degree sequence of causal chain link force. Based on the causal chain structure of the upper limit growth archetype, we have innovatively applied causal chain transfer effect method to prove and analysis the cause of expensive medical bills and difficult access to quality medical services for residents. The correctness of six management countermeasures in subsystem of county hospital development is proposed based on the principle of restricted negative feedback loop in medical service supply chain system of county hospital. Nine rate variable basic in-trees are built. We have innovatively use a new method that-set a new rural cooperative medical rate variable basic in-tree as control parameter to simulate and test the correctness and reliability of countermeasures by causal chain transfer effect.Finally, a series of proposals about China’s new rural health system reform were put forward based on simulation force effect analysis. They are as follows.(1) when making and implementing policies for the new rural cooperative medical system, governments in different level should pay attention to the four forces, including economic support force, inner-generated force, attraction and motive force, and should prompt the new rural cooperative medical system to develop continuously by making the four forces to keep constant reinforce.(2) In the process of health system reform, governments and managers should recognize, before achieving the overall goal of health system reform, it is necessary to firstly realize their own objectives, including government, hospitals, pharmaceutical companies, rural and urban residents.(3) Based on feedback loop effect analysis, the dissertation holds that it will restrict peasants to take part in the new rural cooperation medical system if they pay a high proportion fee. So, the dissertation suggest when making policy for the new rural cooperative medical system, policy-makers should pay attention to control the fee proportion which paid by peasants.(4) The new rural cooperative policy has positive effects on the outpatient, hospital patient, and medical staff in county hospitals, so it is necessary to strengthen the policy and promote the development of county hospitals.(5) It is proved that county hospitals can not afford to finance enough in construction of section and medical equipment on their own based on the feedback simulation analysis, therefore it is necessary to further increase government finance in the construction of county hospitals更多还原