【作者】 刘思垚；

【导师】 王珉；

【作者基本信息】 浙江师范大学 ， 行政管理， 2011， 硕士

【副题名】以辽宁省丹东市为例

【摘要】 按照萨缪尔森在《公共支出的纯理论》中的定义,纯粹的公共产品或劳务是这样的产品或劳务,即每个人消费这种物品或劳务不会导致别人对该种产品或劳务的减少。服务型政府是我国政府建的取向,其主要职能是提供公共产品和公共服务。政府对农村医疗保障这一战略性公共产品供给的质量与效率,直接影响到城乡保障均等化建设与农村居民的国民待遇。新型农村合作医疗制度(以下部分简称新农合),就是在政府的引导下,采取农民自愿筹资,集体扶持,中央政府和地方政府拨款的具有互助共济性质的农村公共医疗保障制度。新型农村合作医疗制度是相对传统农村合作医疗制度而言。伴随着社会经济体制的改革,以人力成本代替物质成本来满足对合作医疗供给的模式也失去了原有的刚性保障,集体经济的解体与人们意识形态的转变使农村公共卫生保障事业向新的制度模式发展。本篇论文共分五个部分,其基本框架与内在逻辑为：第一部分是绪论,首先笔者指出提供公共产品与公共服务是服务型政府主要职能。政府应确保对城市与农村医疗保障的均等化供给。接着强调了地方政府在农村医疗保障中的作用。分析了新农合制度的三个主要特征。借鉴国内外的先进经验与理论研究,对新农合制度进行可行性分析。第二部分与第三部分是实证层面,我国地方政府职能的具体案例,笔者将丹东市新型农村合作医疗制度开展情况作为研究对象,调查了丹东市的农村卫生资源状况、新型农村合作医疗制度的履行情况,及政府对新型农村合作医疗的监管情况,得出新型农村合作医疗制度实施以来所取得的成效,也提出了其运行中存在着制度安排的问题,从具体事实的层面考察与分析现实中的地方政府角色及其职能。第四部分是对新农合中存在的问题进行了理论分析,从公共物品的理论视角阐述了新农合医疗保障性质的农村公共产品属性,分析了在供给中存在着供需机制失衡与供给主体错位等问题。指出新农合制度中的“自愿性”及“大病统筹”原则是逆向选择发生的主要原因,在新农合的医疗卫生服务中存在着医疗服务供需双方的道德风险。第五部分是地方政府在新农合中的对策思考,在理想与现实、理论与实证的两种思考维度与层面下,结合具体问题的分析,笔者指出自上而下的政策制定机制导致了政府的政策及财政供给向城市惯性倾斜,使得城乡公共产品供给的严重失衡,应建立自下而上的表达机制来弥补公共选择机制的缺失。地方政府应从财政保障、监管机制、新农合公共卫生保障体系三个方面履行其政府职能。笔者引用萨瓦斯的理论,即公共服务体系中的生产者和安排者是除消费真之外的两类角色。认为地方政府应在新农合中做好公共产品供给体系的生产者与制度的安排者角色,以生产者的身份构建新型农村三级公共卫生服务体系,以安排者的身份对各级卫生服务机构进行行政体制改革。作为三级公共卫生服务体系中心的县级医院的转型,应以重点专科的建设带动医院的整体发展。最后提出要打破城乡“二元”差异,提高基本卫生医疗服务的均等化水平。更多还原

【Abstract】 According to The Pure Theory of Public Expenditure of Paul A Samuelson, the definition of pure public products or services refers to one person’s use does not reduce the amount available to others. Providing public goods and public services is the main function of the service-type government as well as the mission of improving government performance. The governmental supply efficiency and quality of the rural medical security system-a strategic public products-will affect the equalization of urban and rural security system and national treatment of rural residents. The new rural cooperative medical system(hereinafter abbreviated as NRC), which under the guidance of government to take the voluntary funding of farmers, being supported by the rural economic collectives and defrayed by a central government and local government grant, is a public health care system in rural district with interdependent character. Along with the social economic system reform, the traditional system which takes advantage of human cost instead of material cost to satisfy the cooperative medical supply loses the valid guarantee, for the collective economic disintegration and ideology transformation of people, and the transformation causes the further development of the rural public health security system innovation.This paper is divided into five parts, the basic framework and the internal logic is: The first part is the introduction. First of all, the paper points out that provide public products and public services is the main function of the service-type government, and the government should ensure the equal supply of urban and rural security system. Then the paper emphasizes the role of local government in rural health care system, and analyzes the three main features of the new rural cooperative medical system. Based on the advanced experiences and theoretical studies from both at home and abroad, the paper does the feasibility analysis of the new rural cooperative medical system.In the second part and the third part, in the empirical level, the paper cites the specific examples of the role of local government, makes the development situation of new rural cooperative medical system of Dandong as the research object, investigates circumstance of rural health resource as well as inquires performance of compliance duties and supervision of the new rural cooperative medical system by the government, points out that there are some operational problems in institutional arrangement. From the level of the specific facts, the paper observes and studies the real roles and functions of the local government.In the fourth part, the paper makes theoretical analysis on the problems of the new rural cooperative medical system, expatiates the properties of rural public products with the new rural districts’cooperative medical care character, analyses the problems of unbalanced supply and demand mechanism as well as dislocation of main body in medical supplies, indicates that, "voluntary participation" and "critical illness insurance" are the main reasons which trigger farmers’"adverse selection", and "moral hazard" exists in double-sided of health services in the new rural cooperative medical system.At last, the writer puts forwards the specific methods of local government’s functions in the new rural cooperative medical system. Under the guidance of two ways of logic thinking-ideal and reality, theory and empirical logic, combining the analysis of specific issues, the paper points out that the top-down policy formulation mechanism leds to the urben tilted-policy which causes unbalanced supply mechanism of city and countryside, and the government should set up bottom-up expression mechanism to counterbalance the lack of the public option mechanism. The paper deems that the local governments should perform the functions from the three aspects of financial security, supervision mechanism, new rural public health security system. According to the theory of E. S. Savas, in the public service system, producer and deployer are two kinds of roles in addition to consumer supply of public product system and institution arrangement. The paper gives an idea that the local government can be a major producer of public health services, who sets up a three-tier public health service system in rural districts, and can be a provider in medicare systems, who makes a reform in administration system of rural health service institutions. As the centre of three-tier public health service system, the transformation of county hospital should develop the key specialties to promote the progress of the whole hospital. Finally, the paper proposes that, it is necessary to break up the dual social security structure of urban and rural areas as well as improve the level of equalization of the basic health medical services.更多还原