摘要
目的
本研究在文献研究和政策分析的基础上,通过对抽样地区乡村医生现状的调查分析,明确乡村医生向执业(助理)医师过渡过程中存在的主要问题及其影响因素,根据调查结果,结合政策分析和其他政策经验启示,提出乡村医生向执业(助理)医师过渡的对策建议,为乡村医生向执业(助理)医师过渡提供决策参考。
方法
本研究运用社会学、公共管理学、政策分析理论、卫生统计学等理论和方法,通过理论分析和专家咨询对乡村医生向执业(助理)医师过渡的现状、政策进行了分析。
主要方法包括:
(1)文献研究方法;
(2)现场调查,包括问卷调查和现场访谈;
(3)政策分析方法:分析乡村医生执业过渡各项政策的时代背景、发展状况以及发展趋势以及产生的问题;
(4)统计学方法:主要应用描述统计分析方法,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;
(5)专家咨询法:主要是对访谈和小组讨论的资料进行整理,提取过渡存在的主要问题,再针对各个问题就有关专家和相关人士进行咨询,得出解决问题的方法。
结果
相关法律法规及政策梳理结果:乡村医生向执业(助理)医师过渡时期,针对乡村医生素质低下,执业不规范等问题,国家已制定了一系列的法律法规及政策。
(1)资格认定方面
国家颁布的《执业医师法》和《乡村医生从业管理条例》中对乡村医生资格认定做了规定,这为我国乡村医生向执业(助理)医师过渡提供了法律依据。
(2)教育培训方面
《1991～2000年全国乡村医生教育规划》的实施,标志着我国乡村医生从初等医学教育已迈入了系统化、正规化的中等教育阶段;为了加强乡村医生学历教育,2001年又颁布了第二个十年规划。两个十年规划使我国乡村医生的素质得到了很大的提高,从而使其向执业(助理)医师过渡成为可能。
(3)财政补助及奖励政策
为合理解决农村卫生人员待遇问题,1997年《中共中央、国务院关于卫生改革与发展的决定》中提出村集体卫生组织的乡村医生收入不得低于当地村干部的收入水平;为进一步激励全国广大乡村医生更好地为农民提供基本医疗卫生服务,《乡村医生从业管理条例》规定国家对在农村预防、保健、医疗服务和突发事件应急处理工作中做出突出成绩的乡村医生,给予奖励。
另外,地方政府根据各地实际情况,也制定了一些促进乡村医生执业过渡的政策,为我国乡村医生向执业(助理)医师过渡提供了理论依据和政策支持。通过对六省(市)4160位乡村医生的调查结果显示:
(1)调查地区村卫生室基本情况
平均每个村拥有卫生室1.04个,基本实现村村拥有卫生室;村卫生室举办形式以村办为主,占调查地区的58%,其次是私人举办,占20%;平均每个村卫生室拥有乡村医生2.06人,执业(助理)医师0.09人,不足0.1人,甚至有的县没有执业(助理)医师。
(2)调查地区乡村医生基本情况
有47.13%的乡村医生年龄在45岁以上;从学历结构看,具有中专学历占71.5%,本科及本科以上人员仅占0.53%;目前具备执业(助理)医师资格的乡村医生仅占总人数的9.13%,从年龄、学历对比来看,年龄越大执业化程度越低,学历越高执业化程度也就越高;乡村医生中享受津贴补助的人员只占22.82%,有24.97%的人参加了养老保险,总体上东部参保率高,西部享受津贴补助比例较高。
(3)培训及其意愿调查情况
乡村医生对于国家执业(助理)医师考试的相关规定,知晓率高达96.35%,但是参加考试的人数很少,即使参加考试,通过率也很低。分析其原因,主要是考试难度太大、年龄偏大。另外医学专业学历不符合考试条件要求是不能参加执业考试主要原因之一。针对上述情况,69.62%的人希望政府给予一定政策性照顾,50.62%的人希望得到具有针对性的培训。
结论
目前我国乡村医生仍然面临着“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“到2010年全国大多数乡村医生具备执业(助理)医师及以上资格”的目标,存在较大的困难。
现行政策讨论分析
(1)现有相关政策不完善阻碍医师执业化过渡;(2)现有相关政策之间的冲突导致新的问题出现;(3)政策落实不到位阻碍执业化过渡;(4)缺乏国家层面的社会保障政策;(5)奖励措施不够。
调查结果讨论分析
(1)乡村医生结构不合理是过渡的难点;(2)资格考试方式和内容不符合农村实际;(3)缺乏针对性的培训方式;(4)培训费用过高,乡村医生无力支付;(5)老龄化严重,后继乏人;(6)乡村医生参保率低,养老得不到保障等。
建议
(1)完善现有的相关法律法规及政策,特别是《执业医师法》和《乡村医生从业管理条例》中有关执业医师考试的相关规定,使其更好的促进医师执业过渡;
(2)改革乡村医生人事制度,按照因地制宜,分类指导的原则制定相应政策,不
同经济发展水平地区采用不同标准;
(3)继续加强在岗乡村医生的学历教育、在岗培训和继续教育,组建培训网络,开展有针对性的分层培训;
(4)建立乡村医生保险福利基金,制定乡村医生离岗退养办法,妥善解决乡村医生退休待遇;
(5)通过乡村卫生服务一体化管理,解决乡村医生的身份问题;
(6)以政府购买公共卫生服务的方式合理解决乡村医生报酬问题;
(7)建立在岗人员的激励机制,鼓励医务人员留在农村;
(8)制定乡村医生向全科医师转化的政策。
Objective
This study based on literature research and policy analysis, through surveying on the sampling areas, to find the main issues and their impact factors which hinder the process of transition from rural doctor to licensed physician in china.Then acoording to the issues, with the ellightenments of other policy experience, this paper will put forward policy proposals for the transition, which can make the goal by 2010 achieved as soon as possible.
Methods
The research used the methods and theory of sociology, public health management, and statistics, which aim is to analyze the status quo and policies of the transition from rural doctor to licensed physician. The main methods included:
(1) Literature reasearch;
(2) Spot investigation method including questionnaire and interview;
(3) Policy analysis on the backgrounds, development and progressing tendency of the policies and strategies were analyzed in the research;
(4) Statistical method: main use the descriptive statistics method to analyze rural doctors’status quo and their willingness of examination;
(5) Experts consultation method or Delphi, this method mainly on interviews and group discussions to collate the information, and then conclude the main issues and find the solutions.
Results
Related laws, regulations and policies: in order to solve the problems of low quality and nonstandard qualification of rural doctors, our country has set down a series of related laws, regulations and policies.
(1) Policies on rural doctors’qualification certification
The government has make the qualifying standard by the "Law on Practicing Doctors of the Peoples Rrepublic of China" and "Administrative Regulations for Rural Doctors’Medical practice”, which has provide a legal basis for China's rural doctors’transition.
(2) Policies on Education and Training
The implementation of“the Chinese rural doctors educational programming advanced by the Sanitation department from 1991 to 2000”, signify that China's rural doctors from the primary medical education has entered a systematic, and regularization of the secondary education stage. To further enhance the academic education of rural doctors, the government enacted the second decade planning by 2001. Two decades of China's rural doctors’education plan not only make the quality greatly improved, but also make the transition possible.
(3) The financial subsidy and awarding policy
In order to solve the treatment of rural health workers with reason, the“Decision on the Health Reform and Development by the Party Central Committee and the State Council”proposed village collective income of rural doctors should not be lower than the local village cadres income levels; To further stimulate the nation's rural doctors based on rural areas, service peasants, and better for farmers to provide basic medical and health services, "Administrative Regulations for Rural Doctors’Medical practice”regulate that give incentives to whom make outstanding acaievemment in the rural areas of prevention, health care, medical services and emergency handling of sudden events.
Furthermore,According to their own situations, local government also has set down a series of policies which improve rural doctors obtain the qualification. All of above measures provide theoretic basis and policy support for the transition from rural doctors to licensed physician.
The survey totally collected 4160 questionnaires from rural health rooms of six provinces,the results showed that:
(1) Basic situation of village health posts in sample region: there are 1.04 clinics per village on average; the main form of village health posts is hold by village, accounting for 58% of the survey region, followed by private, accounting for 20%; there are 2.06 rural doctors per village health posts on average, 0.09 licensed physician, Less than 0.1, and even some counties have no licensed physician.
(2) Basic situation of rural doctors in sampling regions: there are 47.13% of the rural doctors aged above 45; from the academic structure, 71.5% of which are secondary school education, 0.53% of which are undergraduate and postgraduate only; currently, only 9.13% of rural doctors have the qualification to be a licensed physician, contrast from age and academic structure, the greater the age, the lower the level of practice; the higher education, the higher the degree of practice; only 22.82 % rural doctors enjoyed the benefits in the staff subsidies, 24.97%of them took part in old-age insurance, Overall, the eastern part had the high rate of participation in insurance,the Western staff enjoyed a higher proportion of grants allowances.
(3) Results of training and willing: the rate of awareness of the practicing examination up to 96.35%, but there are a few to take part in the examination and pass it. For such phenomenon, the research found that the examination is difficult and their age is old. Low educational level is another main reason. 69.62% of the informants hope the government can give some policy support. 50.62% of the informants hope a targeted training. Conclusions
According to the results of spot investigation and the related policy analysis, we can see that China's rural doctors are still faced with the embarrassing situation of "low quality, difficult access to quality, ageing, and no income security". So in the short trem, it is very difficult to achieve the goal, "by the year 2010 with the majority of rural doctors to become the qualified physicians.”
The problems obtained from the survey
(1) Irrational structure of rural doctors is one of main difficulties; (2) Form and content of the examination is not in line with rural realities; (3) Lack of specialized training targeted rural doctorS; (4) Rural doctors unable to pay the high training costs; (5) the phenomenon of ageing is serious; (6) the rate on medical insurance of rural doctor is very low.
The problems obtained from the current policy
(1) The imperfect systerm is also an important reason of the problems; (2) The conflict between relevant policies make the new problems; (3) Current policy is not on the point; (4) Lack of social security policy; (5) Lake of incentive policy.
Suggestions
In order to achieve this transition goal as soon as possible, this paper made the follwing suggestions which comprehensively consider the national laws and regulations, and foreign policy experience on the basis of the survey results. The government should
(1) Make the current relevant policies perfect, especially, "Law on Practicing Doctors of the Peoples Rrepublic of China" and "Administrative Regulations for Country Doctor’Medical practice”;
(2) Reform rural doctors’personnel system, which should take different strategies for different regions;
(3) Continue to strengthen the academic education, incumbency training and continuing education, establish training networks, and develop targeted training method and layered training method;
(4) Establish rural doctors insurance benefits fund, properly solve the problem of retirement and endowment;
(5) Establish the integrated management systerm about rural health services, which to resolve the status of rural doctor;
(6) Purchase public health services to solve the problem of rural doctors’compensation;
(7) Establish the incentive mechanism to encourage medical personnel stay at rural areas;
(8) Develop the policy that can change rural doctors to general practitioners.
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