中国农村合作医疗制度演化机制研究
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摘要
农村合作医疗制度作为农村医疗保障的主体制度,它的完善、发展和演化对于缓解农民医疗负担、促进城乡经济协调发展和构建和谐社会具有重要意义。历史上,我国农村合作医疗制度的演化表现出剧烈的不稳定性;现实中新型农村合作医疗制度的运行存在监督机制不完善、医疗费用快速上涨、保障水平过低等问题,这也加剧了制度系统的不稳定;理论上,缺乏从制度演化视野,对农村合作医疗制度演化机制和动态均衡机制的研究。因此,融合制度演化理论、公共产品理论和博弈论方法,从新的视角来研究农村合作医疗制度变迁的演化机制和博弈关系,对于治理当前制度的内在缺陷、优化农村合作医疗制度的演化方式、促使制度可持续发展,具有积极的理论和现实意义。
本文以制度演化为视角,针对我国农村合作医疗制度的变迁过程,建立了制度演化分析的理论框架,构建了动态的农村合作医疗制度变迁的均衡演化模型和农村合作医疗制度演化的多因素决定模型,并结合历史上不同时期影响农村合作医疗制度变迁的不同因素,对制度的演化机制进行分析。本文还利用博弈论的研究工具,分析了农村合作医疗制度体系中对该制度演化具有决定性作用的行为主体间的博弈结构,从而提炼出影响农村合作医疗制度均衡的条件和影响均衡稳定性的因素。结合对不同时期政府在农村合作医疗制度演化中的作用分析,归纳和阐释了农村合作医疗制度的演化类型、演化方式及其缺陷,并提出了实现农村合作医疗制度创新的途径。通过对城乡分割的医疗保障内在缺陷分析和对构建城乡一体化基本医疗保障必要性的揭示,就农村合作医疗制度的长期演化方向作出了预测和判断,并提出了构建城乡一体化基本医疗保障制度体系的演化路径和目标模式。
本文共分八章:第一章为导论部分,在描述研究背景、研究意义和界定相关概念的基础上,阐述了论文的研究思路和内容框架。
第二章梳理和归纳制度变迁、制度演化相关理论和农村合作医疗制度相关研究的进展情况,试图在现有理论和研究结论的基础上,为以后章节创新性研究农村合作医疗制度的演化机制做好理论铺垫。另外通过对已有相关文献的整理,指出学术界在农村合作医疗制度的演化机制和博弈关系这个研究方向上的不足和空白。
第三章回顾中国农村合作医疗制度变迁的历史过程,对农村合作医疗制度在不同时期的制度安排、运行机制和制度特点进行总结归纳,为以后章节研究作出制度演化历史和背景的铺垫。另外,对当前运行的新型农村合作医疗制度从效率和公平两个角度,进行绩效评价分析,指出该制度在降低农民医疗负担等方面效率不高,并且在制度实施效果上存在一定的不公平。
第四章综合制度变迁理论分析范式和制度演化分析理论,提出了中国农村合作医疗制度变迁的均衡演化模型和农村合作医疗制度演化的多因素决定模型。借助农村合作医疗制度变迁的均衡演化模型指出中国农村合作医疗制度的不均衡(这种不均衡可以表现为农村合作医疗制度内部系统或与外部系统的耦合性的不均衡,也可以表现为农村合作医疗制度的需求与供给的不平衡),是中国农村合作医疗制度演化的内在动力。这种不均衡是由一系列变量所引起的,既有制度系统本身的原因(制度系统内部的耦合关系、制度的费用结构等),也有外在的因素(如政治因素、社会结构、经济结构转型、意识形态、传媒推动等)的作用,但在所有因素中,农村合作医疗所处的制度环境与推动该制度演化的主体至关重要,它们决定了农村合作医疗制度演化的形态,并在促使农村合作医疗制度形成“断点均衡”后,可能成为打破这一断点均衡的“扰动因素”,促使农村合作医疗制度再次面临危机,并发生新一轮的演化,直至形成下一个制度均衡,如此循环往复,构成了农村合作医疗制度演化的动态过程。在农村合作医疗制度演化的多因素决定模型中,指出四类因素影响者农村合作医疗制度演化:一是制度环境,二是行动集团,三是制度效率、制度性质等内源性变量,四是公共政策取向、意识形态等外源性变量。其中农村合作医疗制度变迁主体(行动集团)是关键变量,其成员构成、力量对比、博弈能力等很大程度上决定了均衡的农村合作医疗制度安排。本章就制度环境、内源性变量因素、外源性变量因素如何影响农村合作医疗制度的演化进行了深入分析。
第五章由于农村合作医疗制度的演化形态取决于行为主体间的博弈均衡,本章运用博弈论方法,对政府、医疗机构、农民这三类行为主体在新型农村合作医疗制度中的博弈关系进行分析,通过分析行为主体间的博弈均衡,指出农村合作医疗制度的均衡条件和均衡状态。其中在政府和医疗机构的博弈中,如果政府监管部门检查成本较低、对医疗机构违规行为惩罚力度加大以及医疗机构诚实行医的社会效益较高,则医疗机构诚实行医的概率较大;对于政府,如果医疗机构因不诚实行为而获得的超额收益越小、政府对医疗机构的违规行为惩罚力度越强,则政府进行医疗卫生服务检查的概率就越小。政府和农民博弈的均衡状态取决于双方在博弈中的净收益,均衡的结果是政府在预期收益最大化动机驱使下,选择了由政府组织、引导、支持,农民自愿参加的农村合作医疗制度安排。在这样一种制度安排下,由于信息不对称和大病统筹为主的政策目标取向,农民可能存在逆向选择行为倾向。医疗机构与农民之间博弈的均衡取决于医疗机构不诚实行医时获取的超额收益、农民患大病的概率、农民患大病时得到合作医疗管理机构补偿以及农民在合作医疗中的缴费等因素。在这个静态均衡中隐含了医疗机构出于利益最大化动机的供给诱导需求的行为激励和基于信息不对称条件下的医患双方合谋的道德风险。可以看出各行为主体出于自身预期收益最大化的考虑,导致该制度体系中存在医疗服务需求方的逆向选择问题、医疗服务供给方的诱导需求问题以及医患合谋的道德风险问题等等,从而容易引发制度均衡的不稳定。因此,实现农村合作医疗制度的稳定可持续发展需要政府的干预,其稳定性主要取决于政府对合作医疗所采取的监管力度、监管方式以及集体的信息传播机制等因素。这要求政府加强对乡村医生的人力资本投入、给予医生合适水平的经济收益、给予农民一定的就医选择权力等。
第六章结合政府在农村合作医疗制度中的作用,对不同时期农村合作医疗制度的演化类型进行了分析,指出传统农村合作医疗制度是一种以民间自发演化为基础、政府倡导下的由政府和民间合力推进的制度演化;而新型农村合作医疗制度的创建是一种具有帕累托性质的政府推动的强制式制度演化,并分析了这种强制式制度演化的缺陷,如对民间自主创新的排斥、与其它制度耦合的低效率、民众制度需求的不完全满足以及制度主体间利益兼顾的困难等。进而对政府应在农村合作医疗制度演化中如何发挥作用和应该发挥哪些作用进行了阐释,并对当前施行的新型农村合作医疗制度中的政府责任、作用和问题进行了分析和评价。另外,探讨了实现农村合作医疗制度创新的途径,指出首先应该优化农村合作医疗制度的演化模式,充分发挥民间制度创新动力和市场的资源配置效率,这需要我们对政府在合作医疗中的干预范围、干预限度、干预目标进行重新审视和厘清;其次,应该完善政府在农村医疗保障领域的治理机制,如在医疗保障体系中引入市场竞争机制,建立第三方付费的制衡机制,建立多元化、高效的合作医疗筹资机制,科学合理的费用补偿机制和公开、公正、有效的农村合作医疗监管机制等。
第七章旨在对农村合作医疗制度的长期演化趋势进行理性展望,指出新型农村合作医疗制度将来的发展方向是逐步走向消除城乡分割,融入与城市医疗保障系统相统一、覆盖全民、城乡一体化运作的基本医疗保障制度体系中去。并对这种城乡一体化的医疗保障制度的构建提出了初步构想:首先全力提高农村合作医疗的保障水平和现有医疗保障制度的覆盖率,然后整合城镇居民基本医疗保险和新型农村合作医疗体系,最后全面建立城乡统筹、一体化管理的基本医疗保障制度。
第八章是论文的总体结论部分,试图明确、精炼地阐述论文的主要结论,并指出本文的创新性工作,提出以后需要进一步深入研究的问题。
Rural cooperative medical care system is the centerpiece of rural medical security system. Its improvement, development and evolution play an important role in relieving the farmers' heavy economic burden from the medical care, improving the balanced development of both rural and urban areas and constructing a harmonious society. In history, our rural cooperative medical care system evolved unsteadily. In reality, the new type of rural cooperative medical care system has a series of problems in its operation, such as the incompleteness of the supervising system, the rapid rising of the medical care expenses and the rather low security level. All of these also deepen the instability of the system. In theory, it lacks researches on the evolution mechanism and the dynamic balanced mechanism of the rural cooperative medical care system from the perspective of system evolution. Therefore, it has positive theoretical and realistic significance in managing the internal defects of the present system, promoting its sustainable development and optimizing the evolving pattern of the rural cooperative medical care system if we study the evolution mechanism and the game-playing relations of the rural cooperative medical care system from new perspectives, mixing the system evolution analysis theory, public products theory and game-playing methods together.
Aiming at the changes of our rural cooperative medical care system, this dissertation, from the perspective of system evolution, builds up the theoretical framework of the systematic evolution analysis, constructs a dynamic balanced evolution model of the changes of our rural cooperative medical care system and multi-elements decided model of its evolution and analyzes its evolving mechanism combining the different elements which have influenced those shifts in different historical periods. By applying the game-playing research instrument, this paper analyzes the static and dynamic gaming-playing structures between the disposing subjects which play a decisive role in the evolution of the rural cooperative medical care system. Thus, it extracts the conditions that have influenced the medical care system and those that have influenced the stability of the balance. It sums up and explains the evolution types, patterns and their defects of the rural cooperative medical care system combining the analyses of the role the government plays in different period. Meantime, it suggests the ways to realize creativity in the system. It predicts and judges the direction of the evolution in a long run and points out the evolving roads and objective patterns to construct a rural-urban basic medical insurance system via the analyses on the defects of the system in which the rural and urban areas are separated and exposing the necessity of constructing a rural-urban basic medical insurance system.
This thesis contains eight chapters. Chapter One is introduction. It depicts the research backgrounds, research significance and defines some relevant concepts. Besides it elaborates my train of thought on this research and the framework of the content.
Chapter Two organizes and summarizes the related researches on rural cooperative medical care system and the relevant theories about system changes and system evolution. It tries to pave ways for the following chapters concerning creative researches on the evolving mechanism of the system on the basis of present theories and the previous researches. Furthermore, it points out that the studies on the evolution mechanism and game-playing relations in the academic circles still have some defects and blanks.
Chapter Three recalls the process of the changing Chinese rural cooperative medical care system. It concludes the system management, the operation mechanism and the characteristics of the system in different periods, providing the following chapters with the history and backgrounds of the system evolution. Moreover, it analyzes the evaluation on the results of the present new type of rural cooperative medical care system from the perspectives of efficiency and equality. It finds that this system is inefficient in relieving the medical care burdens of the farmers and that, to some extent, it exists inequality in the result.
Chapter Four points out a balanced evolution model of the changes of our rural cooperative medical care system and a multi-elements decided model of its evolution on the basis of the North's analyzing pattern of changing system theory and system evolution analysis theory. With the help of the balanced evolution model, it finds that Chinese rural cooperative medical care system is imbalanced, which is manifested in the coupling of the inner system and the outer system of the rural cooperative medical care system and the demand and the supply of the system. It becomes the intrinsic driving force of the system evolution. The imbalance is caused by a series of variables. That is to say, we may find the reasons from the system itself such as the coupling relation in it and its expense structure and they may be some external causes, political reasons, social structure, and the transformation of the economic structure, ideology, media promotion and so forth. However, among all these elements, the systematic environment the medical care system is in and the subjects who promote the system evolution are vital. They decide the evolution pattern of the medical care system and help it to form a "breaking-point" balance. Then they may become the "disturbing elements" to break the balance, resulting in the medical system facing a crisis again and a new circle of evolution taking place and then coming to the next systematic balance. All of these phenomena move in a circle, constructing the dynamic evolution of the medical care system. In the multi-elements decided model, it tells four types of elements influencing the evolution of the medical care. The first one is the systematic environment. The second one is the operating group. The third one is the efficiency of the system and its character and other internal variables. The fourth one is the public policy and ideology and other external variables. Among them, the subjects (the operating group) are the key variables. The constitution of the members, the comparison of the forces and the game-playing ability and so on may decide the arrangements of the medical care system to a large degree. This chapter analyzes profoundly how the systematic environment, the internal and external variables affect the evolution of the medical care system.
In Chapter Five, because of the evolution patterns of the rural cooperative medical care system being decided by the game-playing equilibrium between the operating subjects, it begins to use game-playing theory to analyze the game-playing relations of the government, medical care institutions and farmers these three types of operating subjects in the new type of medical care system. It shows the balanced preconditions and the balanced situation of the system via the analyses on the game-playing equilibrium among the subjects. In the game-playing between the government and the medical care institutions, the latter one will treat the farmers more honestly if the inspecting cost of the governmental supervising sections is rather lower and if the medical care institutions will be punished more severely if they break the rules and if they may receive higher social effects thanks to their honesty. For the government, the less extra interests the institutions get from their dishonest treatments and the severer the punishment the government will take, then the smaller the possibility for the government to inspect their health care service is. The equilibrium situation of the game-playing between the government and the farmers lies in the net interests of both sides. The result of the equilibrium is that the government, under the control of maximizing the expected interests, will choose to organize and to instruct and to support the system and the farmers will participate in it according to their own will. Under this arrangement of the system, farmers may have the tendency to choose reversely because of information asymmetry and the serious-diseases-trend policy objectives. The game-playing equilibrium between the institutions and the government is decided by the following elements such as the extra profits gained by their dishonest treatments, the possibility of the farmers having some serious diseases, the compensations the farmers can get from the medical care managing sections of the system and the expenses the farmers need to pay. In this static equilibrium, it implies the moral risks conspired by the medical care institutions and the patients because the institutions intend to maximize its profits and their supplies induce demands in the information asymmetry situation. It exposes that it exists a series of problems in the system, such as the subject who needs medical care making reverse choices, the subject who supplies medical care inducing demands and the the two sides conspiring moral risks, because each operating subjects intend to maximize their expected profits. Therefore, it is easy to cause the instability of the system equilibrium. It points out that the stability of the balance lies in the supervising degree, supervising patterns of the government and the collective media spreading mechanism and other elements.
Chapter Six analyzes the evolution types of the rural cooperative medical care systems in different periods in accordance with the role the government plays in the system. It exposes that the traditional rural cooperative medical care systems are the systematic evolution promoted by the joint efforts of the government who advocates it and the ordinary people who start to evolve it themselves and that the foundation of the new type is a government-promoted forced systematic evolution with the Pareto characteristics. It also analyzes the weak points of this kind of forced systematic evolution, such as it rejecting the independent creativity from the people, it being inefficient when coupling with other systems, it failing to meet the demands of the people for systems and it being difficult to take both the system and the operating subjects' interests into account and so forth. It further explains how the government plays a role and what roles it must play, analyzing and evaluating the governmental responsibilities and the impacts and problems which existing in the present new type of system. Furthermore, it explores the ways to let the system be creative. First, we need to optimize the evolution patterns of the rural cooperative medical care system, making full use of the creative forces of the people and the efficiency of the resources allocation in the market. So the intervening scope, limits and goals of the government in the system should be inspected and collated one more time. Second, the governing mechanism of the government in the insurance field should be perfected, for example, to adopt market competing mechanism, to found a third-side-paying balancing mechanism, and to build up a multisided, high-efficient funding mechanism, a scientific and reasonable expense-implementing mechanism and an open, just, efficient supervising mechanism.
Chapter Seven aims at the rational prospects of the evolving direction of the system in a long run. It shows that the developing direction of the new type of rural cooperative medical care system is to clear up the separation between the rural areas and the urban areas and to merge in the basic medical care insurance system characterizing as uniting with the city medical care insurance system, all-residents included and operating rural and urban areas as a whole. Besides, it gives initial idea on how to construct a rural-urban basic medical insurance system. First, we need to improve the insurance level of the rural cooperative medical care system and to ensure access to the present medical care system for more citizens whole-heartedly. Then, we need to reconstruct the urban basic medical care insurance and the new type of rural cooperative medical care system. Last, we may found an overall rural-urban basic medical care insurance system.
Chapter Eight is the conclusion of this dissertation. It tries to elaborate the main conclusions clearly, precisely, completely and accurately. In addition, it points out the creative work of this paper and the questions that need further research in the future.
本文以制度演化为视角,针对我国农村合作医疗制度的变迁过程,建立了制度演化分析的理论框架,构建了动态的农村合作医疗制度变迁的均衡演化模型和农村合作医疗制度演化的多因素决定模型,并结合历史上不同时期影响农村合作医疗制度变迁的不同因素,对制度的演化机制进行分析。本文还利用博弈论的研究工具,分析了农村合作医疗制度体系中对该制度演化具有决定性作用的行为主体间的博弈结构,从而提炼出影响农村合作医疗制度均衡的条件和影响均衡稳定性的因素。结合对不同时期政府在农村合作医疗制度演化中的作用分析,归纳和阐释了农村合作医疗制度的演化类型、演化方式及其缺陷,并提出了实现农村合作医疗制度创新的途径。通过对城乡分割的医疗保障内在缺陷分析和对构建城乡一体化基本医疗保障必要性的揭示,就农村合作医疗制度的长期演化方向作出了预测和判断,并提出了构建城乡一体化基本医疗保障制度体系的演化路径和目标模式。
本文共分八章:第一章为导论部分,在描述研究背景、研究意义和界定相关概念的基础上,阐述了论文的研究思路和内容框架。
第二章梳理和归纳制度变迁、制度演化相关理论和农村合作医疗制度相关研究的进展情况,试图在现有理论和研究结论的基础上,为以后章节创新性研究农村合作医疗制度的演化机制做好理论铺垫。另外通过对已有相关文献的整理,指出学术界在农村合作医疗制度的演化机制和博弈关系这个研究方向上的不足和空白。
第三章回顾中国农村合作医疗制度变迁的历史过程,对农村合作医疗制度在不同时期的制度安排、运行机制和制度特点进行总结归纳,为以后章节研究作出制度演化历史和背景的铺垫。另外,对当前运行的新型农村合作医疗制度从效率和公平两个角度,进行绩效评价分析,指出该制度在降低农民医疗负担等方面效率不高,并且在制度实施效果上存在一定的不公平。
第四章综合制度变迁理论分析范式和制度演化分析理论,提出了中国农村合作医疗制度变迁的均衡演化模型和农村合作医疗制度演化的多因素决定模型。借助农村合作医疗制度变迁的均衡演化模型指出中国农村合作医疗制度的不均衡(这种不均衡可以表现为农村合作医疗制度内部系统或与外部系统的耦合性的不均衡,也可以表现为农村合作医疗制度的需求与供给的不平衡),是中国农村合作医疗制度演化的内在动力。这种不均衡是由一系列变量所引起的,既有制度系统本身的原因(制度系统内部的耦合关系、制度的费用结构等),也有外在的因素(如政治因素、社会结构、经济结构转型、意识形态、传媒推动等)的作用,但在所有因素中,农村合作医疗所处的制度环境与推动该制度演化的主体至关重要,它们决定了农村合作医疗制度演化的形态,并在促使农村合作医疗制度形成“断点均衡”后,可能成为打破这一断点均衡的“扰动因素”,促使农村合作医疗制度再次面临危机,并发生新一轮的演化,直至形成下一个制度均衡,如此循环往复,构成了农村合作医疗制度演化的动态过程。在农村合作医疗制度演化的多因素决定模型中,指出四类因素影响者农村合作医疗制度演化:一是制度环境,二是行动集团,三是制度效率、制度性质等内源性变量,四是公共政策取向、意识形态等外源性变量。其中农村合作医疗制度变迁主体(行动集团)是关键变量,其成员构成、力量对比、博弈能力等很大程度上决定了均衡的农村合作医疗制度安排。本章就制度环境、内源性变量因素、外源性变量因素如何影响农村合作医疗制度的演化进行了深入分析。
第五章由于农村合作医疗制度的演化形态取决于行为主体间的博弈均衡,本章运用博弈论方法,对政府、医疗机构、农民这三类行为主体在新型农村合作医疗制度中的博弈关系进行分析,通过分析行为主体间的博弈均衡,指出农村合作医疗制度的均衡条件和均衡状态。其中在政府和医疗机构的博弈中,如果政府监管部门检查成本较低、对医疗机构违规行为惩罚力度加大以及医疗机构诚实行医的社会效益较高,则医疗机构诚实行医的概率较大;对于政府,如果医疗机构因不诚实行为而获得的超额收益越小、政府对医疗机构的违规行为惩罚力度越强,则政府进行医疗卫生服务检查的概率就越小。政府和农民博弈的均衡状态取决于双方在博弈中的净收益,均衡的结果是政府在预期收益最大化动机驱使下,选择了由政府组织、引导、支持,农民自愿参加的农村合作医疗制度安排。在这样一种制度安排下,由于信息不对称和大病统筹为主的政策目标取向,农民可能存在逆向选择行为倾向。医疗机构与农民之间博弈的均衡取决于医疗机构不诚实行医时获取的超额收益、农民患大病的概率、农民患大病时得到合作医疗管理机构补偿以及农民在合作医疗中的缴费等因素。在这个静态均衡中隐含了医疗机构出于利益最大化动机的供给诱导需求的行为激励和基于信息不对称条件下的医患双方合谋的道德风险。可以看出各行为主体出于自身预期收益最大化的考虑,导致该制度体系中存在医疗服务需求方的逆向选择问题、医疗服务供给方的诱导需求问题以及医患合谋的道德风险问题等等,从而容易引发制度均衡的不稳定。因此,实现农村合作医疗制度的稳定可持续发展需要政府的干预,其稳定性主要取决于政府对合作医疗所采取的监管力度、监管方式以及集体的信息传播机制等因素。这要求政府加强对乡村医生的人力资本投入、给予医生合适水平的经济收益、给予农民一定的就医选择权力等。
第六章结合政府在农村合作医疗制度中的作用,对不同时期农村合作医疗制度的演化类型进行了分析,指出传统农村合作医疗制度是一种以民间自发演化为基础、政府倡导下的由政府和民间合力推进的制度演化;而新型农村合作医疗制度的创建是一种具有帕累托性质的政府推动的强制式制度演化,并分析了这种强制式制度演化的缺陷,如对民间自主创新的排斥、与其它制度耦合的低效率、民众制度需求的不完全满足以及制度主体间利益兼顾的困难等。进而对政府应在农村合作医疗制度演化中如何发挥作用和应该发挥哪些作用进行了阐释,并对当前施行的新型农村合作医疗制度中的政府责任、作用和问题进行了分析和评价。另外,探讨了实现农村合作医疗制度创新的途径,指出首先应该优化农村合作医疗制度的演化模式,充分发挥民间制度创新动力和市场的资源配置效率,这需要我们对政府在合作医疗中的干预范围、干预限度、干预目标进行重新审视和厘清;其次,应该完善政府在农村医疗保障领域的治理机制,如在医疗保障体系中引入市场竞争机制,建立第三方付费的制衡机制,建立多元化、高效的合作医疗筹资机制,科学合理的费用补偿机制和公开、公正、有效的农村合作医疗监管机制等。
第七章旨在对农村合作医疗制度的长期演化趋势进行理性展望,指出新型农村合作医疗制度将来的发展方向是逐步走向消除城乡分割,融入与城市医疗保障系统相统一、覆盖全民、城乡一体化运作的基本医疗保障制度体系中去。并对这种城乡一体化的医疗保障制度的构建提出了初步构想:首先全力提高农村合作医疗的保障水平和现有医疗保障制度的覆盖率,然后整合城镇居民基本医疗保险和新型农村合作医疗体系,最后全面建立城乡统筹、一体化管理的基本医疗保障制度。
第八章是论文的总体结论部分,试图明确、精炼地阐述论文的主要结论,并指出本文的创新性工作,提出以后需要进一步深入研究的问题。
Rural cooperative medical care system is the centerpiece of rural medical security system. Its improvement, development and evolution play an important role in relieving the farmers' heavy economic burden from the medical care, improving the balanced development of both rural and urban areas and constructing a harmonious society. In history, our rural cooperative medical care system evolved unsteadily. In reality, the new type of rural cooperative medical care system has a series of problems in its operation, such as the incompleteness of the supervising system, the rapid rising of the medical care expenses and the rather low security level. All of these also deepen the instability of the system. In theory, it lacks researches on the evolution mechanism and the dynamic balanced mechanism of the rural cooperative medical care system from the perspective of system evolution. Therefore, it has positive theoretical and realistic significance in managing the internal defects of the present system, promoting its sustainable development and optimizing the evolving pattern of the rural cooperative medical care system if we study the evolution mechanism and the game-playing relations of the rural cooperative medical care system from new perspectives, mixing the system evolution analysis theory, public products theory and game-playing methods together.
Aiming at the changes of our rural cooperative medical care system, this dissertation, from the perspective of system evolution, builds up the theoretical framework of the systematic evolution analysis, constructs a dynamic balanced evolution model of the changes of our rural cooperative medical care system and multi-elements decided model of its evolution and analyzes its evolving mechanism combining the different elements which have influenced those shifts in different historical periods. By applying the game-playing research instrument, this paper analyzes the static and dynamic gaming-playing structures between the disposing subjects which play a decisive role in the evolution of the rural cooperative medical care system. Thus, it extracts the conditions that have influenced the medical care system and those that have influenced the stability of the balance. It sums up and explains the evolution types, patterns and their defects of the rural cooperative medical care system combining the analyses of the role the government plays in different period. Meantime, it suggests the ways to realize creativity in the system. It predicts and judges the direction of the evolution in a long run and points out the evolving roads and objective patterns to construct a rural-urban basic medical insurance system via the analyses on the defects of the system in which the rural and urban areas are separated and exposing the necessity of constructing a rural-urban basic medical insurance system.
This thesis contains eight chapters. Chapter One is introduction. It depicts the research backgrounds, research significance and defines some relevant concepts. Besides it elaborates my train of thought on this research and the framework of the content.
Chapter Two organizes and summarizes the related researches on rural cooperative medical care system and the relevant theories about system changes and system evolution. It tries to pave ways for the following chapters concerning creative researches on the evolving mechanism of the system on the basis of present theories and the previous researches. Furthermore, it points out that the studies on the evolution mechanism and game-playing relations in the academic circles still have some defects and blanks.
Chapter Three recalls the process of the changing Chinese rural cooperative medical care system. It concludes the system management, the operation mechanism and the characteristics of the system in different periods, providing the following chapters with the history and backgrounds of the system evolution. Moreover, it analyzes the evaluation on the results of the present new type of rural cooperative medical care system from the perspectives of efficiency and equality. It finds that this system is inefficient in relieving the medical care burdens of the farmers and that, to some extent, it exists inequality in the result.
Chapter Four points out a balanced evolution model of the changes of our rural cooperative medical care system and a multi-elements decided model of its evolution on the basis of the North's analyzing pattern of changing system theory and system evolution analysis theory. With the help of the balanced evolution model, it finds that Chinese rural cooperative medical care system is imbalanced, which is manifested in the coupling of the inner system and the outer system of the rural cooperative medical care system and the demand and the supply of the system. It becomes the intrinsic driving force of the system evolution. The imbalance is caused by a series of variables. That is to say, we may find the reasons from the system itself such as the coupling relation in it and its expense structure and they may be some external causes, political reasons, social structure, and the transformation of the economic structure, ideology, media promotion and so forth. However, among all these elements, the systematic environment the medical care system is in and the subjects who promote the system evolution are vital. They decide the evolution pattern of the medical care system and help it to form a "breaking-point" balance. Then they may become the "disturbing elements" to break the balance, resulting in the medical system facing a crisis again and a new circle of evolution taking place and then coming to the next systematic balance. All of these phenomena move in a circle, constructing the dynamic evolution of the medical care system. In the multi-elements decided model, it tells four types of elements influencing the evolution of the medical care. The first one is the systematic environment. The second one is the operating group. The third one is the efficiency of the system and its character and other internal variables. The fourth one is the public policy and ideology and other external variables. Among them, the subjects (the operating group) are the key variables. The constitution of the members, the comparison of the forces and the game-playing ability and so on may decide the arrangements of the medical care system to a large degree. This chapter analyzes profoundly how the systematic environment, the internal and external variables affect the evolution of the medical care system.
In Chapter Five, because of the evolution patterns of the rural cooperative medical care system being decided by the game-playing equilibrium between the operating subjects, it begins to use game-playing theory to analyze the game-playing relations of the government, medical care institutions and farmers these three types of operating subjects in the new type of medical care system. It shows the balanced preconditions and the balanced situation of the system via the analyses on the game-playing equilibrium among the subjects. In the game-playing between the government and the medical care institutions, the latter one will treat the farmers more honestly if the inspecting cost of the governmental supervising sections is rather lower and if the medical care institutions will be punished more severely if they break the rules and if they may receive higher social effects thanks to their honesty. For the government, the less extra interests the institutions get from their dishonest treatments and the severer the punishment the government will take, then the smaller the possibility for the government to inspect their health care service is. The equilibrium situation of the game-playing between the government and the farmers lies in the net interests of both sides. The result of the equilibrium is that the government, under the control of maximizing the expected interests, will choose to organize and to instruct and to support the system and the farmers will participate in it according to their own will. Under this arrangement of the system, farmers may have the tendency to choose reversely because of information asymmetry and the serious-diseases-trend policy objectives. The game-playing equilibrium between the institutions and the government is decided by the following elements such as the extra profits gained by their dishonest treatments, the possibility of the farmers having some serious diseases, the compensations the farmers can get from the medical care managing sections of the system and the expenses the farmers need to pay. In this static equilibrium, it implies the moral risks conspired by the medical care institutions and the patients because the institutions intend to maximize its profits and their supplies induce demands in the information asymmetry situation. It exposes that it exists a series of problems in the system, such as the subject who needs medical care making reverse choices, the subject who supplies medical care inducing demands and the the two sides conspiring moral risks, because each operating subjects intend to maximize their expected profits. Therefore, it is easy to cause the instability of the system equilibrium. It points out that the stability of the balance lies in the supervising degree, supervising patterns of the government and the collective media spreading mechanism and other elements.
Chapter Six analyzes the evolution types of the rural cooperative medical care systems in different periods in accordance with the role the government plays in the system. It exposes that the traditional rural cooperative medical care systems are the systematic evolution promoted by the joint efforts of the government who advocates it and the ordinary people who start to evolve it themselves and that the foundation of the new type is a government-promoted forced systematic evolution with the Pareto characteristics. It also analyzes the weak points of this kind of forced systematic evolution, such as it rejecting the independent creativity from the people, it being inefficient when coupling with other systems, it failing to meet the demands of the people for systems and it being difficult to take both the system and the operating subjects' interests into account and so forth. It further explains how the government plays a role and what roles it must play, analyzing and evaluating the governmental responsibilities and the impacts and problems which existing in the present new type of system. Furthermore, it explores the ways to let the system be creative. First, we need to optimize the evolution patterns of the rural cooperative medical care system, making full use of the creative forces of the people and the efficiency of the resources allocation in the market. So the intervening scope, limits and goals of the government in the system should be inspected and collated one more time. Second, the governing mechanism of the government in the insurance field should be perfected, for example, to adopt market competing mechanism, to found a third-side-paying balancing mechanism, and to build up a multisided, high-efficient funding mechanism, a scientific and reasonable expense-implementing mechanism and an open, just, efficient supervising mechanism.
Chapter Seven aims at the rational prospects of the evolving direction of the system in a long run. It shows that the developing direction of the new type of rural cooperative medical care system is to clear up the separation between the rural areas and the urban areas and to merge in the basic medical care insurance system characterizing as uniting with the city medical care insurance system, all-residents included and operating rural and urban areas as a whole. Besides, it gives initial idea on how to construct a rural-urban basic medical insurance system. First, we need to improve the insurance level of the rural cooperative medical care system and to ensure access to the present medical care system for more citizens whole-heartedly. Then, we need to reconstruct the urban basic medical care insurance and the new type of rural cooperative medical care system. Last, we may found an overall rural-urban basic medical care insurance system.
Chapter Eight is the conclusion of this dissertation. It tries to elaborate the main conclusions clearly, precisely, completely and accurately. In addition, it points out the creative work of this paper and the questions that need further research in the future.
引文
[1]数据来源:卫生部编制的《中国卫生统计年鉴2008》,中国协和医科大学出版社
[2]卫生部,《第三次国家卫生服务调查主要结果》,2004年,详见http://www.moh.gov.cn/public/open.aspx?n_id=8981&seq=0
[4]以上数据分别来自2009年3月5日国务阮总理温冢宝在弟十一届全国人氏代表大会弟二仄会议上所作的《政府工作报告》和卫生部编制的《中国卫生统计年鉴2008》
[1]周其仁.全盘公费医疗是个梦.经济观察报,2007年5月28日
[2]顾昕.走向全民医保的制度选择:公费医疗制还是社保制.南方周末,2006年3月29日
[1]世界卫生组织:和谐社会与健康--构建惠及全民的中国卫生保健体制,中国医药卫生体制改革国际研讨会会议材料,2007年
[1]世界银行.投资与健康,1993:210-211
[2]世界卫生组织在《2000年世界卫生报告》中对191个会员国的卫生系统进行了绩效评估,在卫生负担公平性方面,中国被捧列在第188位,属于世界上最不公平的国家
[3]1955年-2002年数据,为参加农村合作医疗的村占全国行政村的百分比;2003年-2008年数据为参合率,即参加合作医疗农村人口占全部农村人口的比例
[1]数据来自卫生部主编的‘中国卫生统计年鉴2008》,中国协和医科大学出版社,第207页
[2]王绍光.人民的健康也是硬道理.读书,2003(7)
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[2]关于传统农村合作医疗制度的特点和经验参考了陈文玲教授主持,左慧、张鹏、董立淳等参与的中国医药卫生体制改革目标模式研究课题中的中国医疗保障体制目标模式与框架研究部分(该部分执笔人张鹏)。
[1]中共中央、国务院关于卫生改革与发展的决定,中发[1997]3号
[1]《中共中央、国务院关于进一步加强农村卫生工作的决定》(中发[2002113号),2002年10月19日
[2]《国务院办公厅转发卫生部等部门关于建立新型农村合作医疗制度意见的通知》,(国办发[2003]3号),2003年1月16日
[1]《国务院办公厅转发卫生部等部门关于进一步做好新型农村合作医疗试点工作指导意见的通知》(国办发[2004]3号),2004年1月13日
[2]卫生部网站:2008年我国卫生改革与发展情况,http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohbgt/s6690/200902/39109.htm
[3]中华人民共和国中央人民政府网站http://www.gov,cn/jrzg/2008-02/15/content_890736.htm
[1]《国务院办公厅转发卫生部等部门关于建立新型农村合作医疗制度意见的通知》(国办发[2003]3号),2003年1月16日
[1]数据来源:卫生部编制的《中国卫生统计年鉴2005》,中国协和医科大学出版社
[1]数据来源:卫生部编制的《中国卫生统计年鉴2005》,中国协和医科大学出版社
[1]来源:卫生部网站,2008年我国卫生改革与发展情况
[1]这里的医疗机构指农村合作医疗的定点医院、卫生院
[1]资料来源:人民网http://finance.people.com.cn/GB/1040/59941/8860602.html
[1]卫生部,第三次国家卫生服务调查主要结果,2004年,详见http://www.moh.gov.cn/public/open.aspx?n_id=8981&seq=0
[1]卫生部,第三次国家卫生服务调查主要结果,2004年
[1]中华人民共和国卫生部编.2008年中国卫生统计年鉴,中国协和医科大学出版社
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[4]以上数据分别来自2009年3月5日国务阮总理温冢宝在弟十一届全国人氏代表大会弟二仄会议上所作的《政府工作报告》和卫生部编制的《中国卫生统计年鉴2008》
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[1]世界卫生组织:和谐社会与健康--构建惠及全民的中国卫生保健体制,中国医药卫生体制改革国际研讨会会议材料,2007年
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[3]1955年-2002年数据,为参加农村合作医疗的村占全国行政村的百分比;2003年-2008年数据为参合率,即参加合作医疗农村人口占全部农村人口的比例
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[1]INFOBANK,《中国卫生年鉴1999》,中国主要年份高中等医药院校数及在校学生、招生数统计(1949-1998)
[1]INFOBANK,《中国卫生年鉴2002》,中国主要年份农村乡(镇)卫生院机构、床位、人员数统计(1965-2001)
[2]关于传统农村合作医疗制度的特点和经验参考了陈文玲教授主持,左慧、张鹏、董立淳等参与的中国医药卫生体制改革目标模式研究课题中的中国医疗保障体制目标模式与框架研究部分(该部分执笔人张鹏)。
[1]中共中央、国务院关于卫生改革与发展的决定,中发[1997]3号
[1]《中共中央、国务院关于进一步加强农村卫生工作的决定》(中发[2002113号),2002年10月19日
[2]《国务院办公厅转发卫生部等部门关于建立新型农村合作医疗制度意见的通知》,(国办发[2003]3号),2003年1月16日
[1]《国务院办公厅转发卫生部等部门关于进一步做好新型农村合作医疗试点工作指导意见的通知》(国办发[2004]3号),2004年1月13日
[2]卫生部网站:2008年我国卫生改革与发展情况,http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohbgt/s6690/200902/39109.htm
[3]中华人民共和国中央人民政府网站http://www.gov,cn/jrzg/2008-02/15/content_890736.htm
[1]《国务院办公厅转发卫生部等部门关于建立新型农村合作医疗制度意见的通知》(国办发[2003]3号),2003年1月16日
[1]数据来源:卫生部编制的《中国卫生统计年鉴2005》,中国协和医科大学出版社
[1]数据来源:卫生部编制的《中国卫生统计年鉴2005》,中国协和医科大学出版社
[1]来源:卫生部网站,2008年我国卫生改革与发展情况
[1]这里的医疗机构指农村合作医疗的定点医院、卫生院
[1]资料来源:人民网http://finance.people.com.cn/GB/1040/59941/8860602.html
[1]卫生部,第三次国家卫生服务调查主要结果,2004年,详见http://www.moh.gov.cn/public/open.aspx?n_id=8981&seq=0
[1]卫生部,第三次国家卫生服务调查主要结果,2004年
[1]中华人民共和国卫生部编.2008年中国卫生统计年鉴,中国协和医科大学出版社
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