新农合制度下农村基层医疗服务质量及其治理研究
|
摘要
本文是关于新型农村合作医疗政策下的农村基层医疗服务质量及其治理研究。新型农村合作医疗政策激活了一大批农村基层医疗机构,在事实上增强了乡镇卫生院和村卫生室的地位和作用,尤其是在新农合制度设计中处于枢纽地位的乡镇卫生院,在国家层面受到政府前所未有重视。我国农村基层卫生工作得以迅速开展,呈现出农村居民看病受益、定点医疗机构业务收入增加、卫生事业发展的“多赢”局面。在农村卫生事业水平整体改善的同时,乡村两级基层医疗卫生机构的医疗服务问题引起了越来越多的研究和政策关注。新型农村合作医疗能否正常运作的关键,在于是否拥有一个质优价廉的医疗服务供给系统,当前新型农村合作医疗服务主要由县、乡、村三级医疗卫生服务网承担：县级医疗机构主要负责以住院为主的疾病诊治及危重急症病人的抢救,乡镇卫生院负责提供常见病、多发病的诊疗,村卫生室承担所在行政村的一般疾病的诊治工作。农村三级医疗网应该有效地分流农村患者,使农村居民的大部分基本医疗需求在基层医疗卫生机构得到满足。但是,由于我国城乡医疗资源配置失衡和不公平,乡村两级医疗服务机构普遍面临人力资源、技术能力和设备建设滞后的局面,无法为新农合的正常运转提供可靠的服务和质量保障。尽管新农合通过提高补偿比例等手段鼓励农村居民更多地选择基层医疗机构,然而农村基层医疗的服务水平和质量不能让参合农民满意,尤其在遇“大病”需要治疗的时候,参合农民宁愿选择价格高、路途远的县级以上医院。因此,目前的农村基层医疗服务机构,无法为新农合的正常运转提供可靠的组织保障,也没有很好实现新农合制度缓解农民“看病贵、看病难”的初衷。农村基层医疗服务质量的优劣直接关系到广大农村居民的健康和切身经济利益,加强农村基层医疗服务质量建设和管理,是当前和今后巩固和发展农村合作医疗的关键环节。
本研究试图通过对我国部分地区乡镇卫生院和村卫生室医疗服务质量的调查研究,总结和分析新农合实施后农村基层医疗服务质量的现状、问题和根源。并将利益相关者和治理理论引入农村基层医疗服务质量研究领域,从利益相关者治理的视角探索农村基层医疗服务质量提升的策略和措施,为新农合成熟规范运行提供有力的理论和实践依据。
一、论文的研究内容
第一部分(第1章、第2章)：通过背景分析与文献研究回顾阐明研究的问题。包括选题的提出与选题的意义、研究的主要内容、基本思路和主要方法。回顾与梳理国内外医疗服务治理实践及相关理论研究,形成对医疗卫生服务质量问题、治理及利益相关者理论的认识。
第二部分(第3章、第4章、第5章)：在农村合作医疗制度变迁与农村医疗卫生体制改革的宏观背景下,阐述农村基层医疗卫生服务系统的产生、发展及其现实状态,运用双重差分模型探讨新农合政策对农村基层医疗服务格局的影响；在经济学视角分析农村医疗卫生服务需求与供给的基础上,以作为新型农村合作医疗主要基层定点医疗机构的乡镇卫生院和村卫生室为切入点,运用结构方程分析等定量方法从供需双方的角度探讨影响乡镇卫生院、村卫生室医疗服务质量的主要因素；通过样本地区乡镇卫生院和村卫生室服务质量的问卷及访谈调查,结合国家公布的数据资料,总结和分析新农合实施后农村基层医疗服务质量的现状、问题和根源。
第三部分(第6章、第7章)：运用德尔菲法、问卷及访谈等调查研究方法对新农合基层医疗服务机构的利益相关者进行界定、分类及利益取向、利益冲突分析,寻找利益相关者协同治理的条件与机制。通过正反馈、负反馈及延迟结构分析,围绕新农合基层医疗服务机构的核心利益相关者进行医疗质量问题基模分析。将众多的核心利益相关者整合为政府子系统、农村基层医疗卫生机构子系统、患者子系统、新农合管理者子系统和药品供应商子系统,采用图形结构进行系统基模分析,从利益相关者视角探讨新农合制度下农村基层医疗服务质量的改善策略。
第四部分(第8章)：展开新农合下农村基层医疗服务质量利益相关者协同治理设计。按照治理目标、治理结构、治理机制的结构框架来阐明新农合下农村基层医疗服务质量治理的过程与机制。构建农村基层医疗服务质量协同治理的效用模型,通过模型更为深入地刻画农村基层医疗服务质量治理的关键点与作用机制,提出全新的农村基层医疗服务质量的治理思路。
第五部分(第9章)：总结研究结论,提出相应的政策建议,并展望后续研究。
二、论文的主要结论
1、新型合作医疗制度给农村基层医疗服务机构带来了发展机遇的同时也对基层医疗服务质量提出了挑战,质量问题已成为农村基层医疗机构发展的瓶颈,也成为新农合有效运转的绊脚石。新农合本身作为一种资源配置的机制,采取何种付费方式以及主要的付费流向,对于农民的就医行为以及各定点医疗机构的服务行为,都有深刻的影响。本文通过对CHNS筛选数据的双重差分模型分析表明,新农合持续提高了患者到乡镇卫生院就诊比例,政策的实施使得农村居民的就医流向趋于基层医疗机构。我国农村地区基本形成了县、乡、村三级卫生网络布局,农村居民的医疗服务“可及性”较好,但是由于农村乡、村两级基层医疗卫生机构的技术水平较差,农村居民遇到“大病”宁愿舍近求远地选择县级及县级以上医院,导致城市医院拥挤、看病难,而农村基层医疗机构设备闲置、人才流失的恶性循环。
2、无论是研究者还是政策制定者,都需要正确找寻当前我国农村基层医疗服务中存在的质量问题,目前农村基层医疗服务质量问题主要表现在：技术水平较差、药物滥用和诊疗行为不规范的等方面。在当前农村合作医疗制度框架下,从供需两个角度的调查分析发现,乡镇卫生院(供方)比较重视医疗服务技术性质量,主要包括诊疗质量、合理用药、临床诊疗规范等内容；患者(需方)对乡镇卫生院质量问题的反映主要集中在医生诊疗水平、设备条件、职业道德态度、医疗费用等方面；村卫生室(供方)目前关注的主要有：诊疗质量、器械消毒、人员资质等内容；患者(需方)对村卫生室的主要质量问题反映在设备条件差、药品种类少等方面。乡镇卫生院医疗服务质量问题产生的原因主要表现在：医疗技术人员缺乏、内部有效质量管理和外部质量监控机制缺失；村卫生室医疗质量问题显得更为模糊,村卫生室机构的建设和发展政策不明朗是影响村卫生室医疗质量管理的根源问题。
3、新型农村合作医疗的实施和农村医疗卫生服务的提供,都出现政府“包揽一切,,的倾向,政策的制定并没有顾及不同群体的利益诉求,影响了医疗服务最初目标的实现,同时导致基层医疗服务质量管理与监督的无力。由于医疗服务产品本身的公益性、服务供给的垄断性和供给诱导性的特点,决定了消费者的支付意愿,同时也决定了服务提供者的供给意愿。从管理学的角度分析,政府是新农合的制度设计者与组织者,新农合的实施使原来简单的医患双方转变为政府、医疗机构和参合农民的三方关系。现行新农合的制度设计过多地强调医疗费用的控制而忽视了对定点医疗机构服务质量的监管,参合农民对医疗机构服务质量缺乏有效的监督渠道和投诉机制,导致农村基层医疗服务质量无法得到保证和改善。
4、医疗服务质量的治理实际上是对医疗服务机构的治理,在新型合作医疗的政策框架下,乡镇卫生院与村卫生室作为提供基本医疗服务和公共卫生服务的特殊复合型组织,其利益相关者众多且存在利益冲突,利益的协调与整合是农村基层医疗服务质量治理的关键。农村基层医疗服务机构的利益相关者是对医疗服务进行了“投资”,并承担医疗服务结果可能造成的风险的个人或群体。按照他们在医疗服务中的地位和作用不同,分为核心利益相关者、中间利益相关者和边缘利益相关者。由于不同利益相关者利益目标的差异性,存在着以下几种利益冲突：第一,医疗服务消费者与提供者及其代理人(医生)之间的利益冲突；第二,各级政府及其职能部门、新农合管理办公室、乡镇卫生院、村医及农村居民等利益相关者,在医疗服务目标的偏好及选择不一致时产生的利益冲突,这些冲突的协调是重要的治理着力点。
5、系统基模分析从不同利益相关者的角度解释了农村基层医疗服务现存的治理问题及原因。农村基层医疗卫生机构在“市场化”浪潮下转变了医疗卫生工作的重点和医疗卫生工作的性质。一方面,这种“市场化”的大环境让农村三级卫生网络中的主角——乡镇卫生院和村卫生室由层级间的协作关系变质为层级间的竞争关系,使农村基层医疗服务的纵向整合质量降低。另一方面,随着经济体制的变革,乡镇卫生院和村卫生室基本上已经成为相互独立的市场主体。为了重塑农村基层医疗卫生工作的秩序化和完整性,20世纪90年代后国家提出了“乡村卫生管理一体化”的政策。但是,当前的乡镇卫生院与村卫生室的关系,实质上是乡镇卫生院受地方政府的委托对村卫生室进行管理。这种委托管理在所有权缺失的情况下,容易产生违规操作、与村医争利以及利益分配不公平的问题,这些失范行为导致农村基层医疗服务的目标侵蚀。
6、当前农村基层医疗卫生机构在“公益”、“福利”、“非营利”等属性上飘移、争论,新型合作医疗管理机构也陷入“督”与“办”的含混境地,破解农村基层医疗服务质量问题的关键是质量监督机制的重塑。①新型农村合作医疗的推行,在一定程度上影响了农村基层医疗服务的利益格局。虽然乡镇卫生院与村卫生室之间的医疗业务定位不同但两者之间仍然存在较为激烈的竞争关系。因此,在新型农村合作医疗制度框架下,可逐步打破各自为政的格局。村医可充当新农合的“守门人”中色,通过首诊过滤,建立村、乡、县逐级转诊制度。②乡镇卫生院和村卫生室不能向一般的医院模式和诊所方向发展,因为乡镇卫生院和村卫生室还受国家卫生行政部门委托,承担了公共卫生服务的职能。建议落实农村基层医疗卫生的乡村一体化管理,在乡镇卫生院与村卫生室的纵向业务分工合作的基础上,制定不同层次的质量监督机制。
7、由于新农合制度设计中特殊的多层级委托—代理关系,在农村地区乡村两级医疗机构服务质量的内部治理中,各核心利益相关者随着医疗卫生服务的延伸环节进行质量的治理。包括医患关系的治理结构、医院运营的治理结构、新型农村合作医疗保险环节的治理结构。可以考虑在政府引导下设置由核心利益相关者代表组成的农村基层医疗服务质量治理的实体组织,对农村基层医疗服务进行客观、独立的第三方协调与监督。外部治理的重点则主要是政府外部治理平台的打造以及市场机制与社会监督机制的完善。
三、论文的创新之处
1、采用供需双方视角的分析,较为准确地发现了新农合乡村两级定点医疗机构服务质量的主要问题。通过对乡镇卫生院和村卫生室进行医疗服务质量的定量、定性分析,发现乡镇卫生院和村卫生室(供方)比较重视医疗服务技术性质量,而患者(需方)对基层医疗服务质量问题的反映则更倾向于非技术性质量维度,这为改善农村基层医疗服务质量提供了实证依据和启示。
2、提出了农村基层医疗服务质量利益相关者协同治理的思路。已有的治理研究多是政府或医院视角的单边治理,本研究将利益相关者与治理理论引入新农合农村基层医疗服务质量的研究领域,把乡镇卫生院和村卫生室作为特殊复合型组织,根据农村基层医疗服务质量体系的治理目标,探索了农村基层医疗服务质量利益相关者协同治理的目标、治理结构和运行机制,为政府改善和提高农村基层医疗服务质量提供决策参考。
This dissertation is a study on quality and governance for the rural basic medical service under the new rural cooperative medical system. The new rural cooperative medical policy to activate a large number of rural grassroots medical institutions,in fact enhanced township hospitals and village clinics in the status and role, especially the township hospitals which are the hub in the new rural cooperative medical system design and paid the unprecedented attention to by the government at the national level.With China's rapid development of rural health work, There appear the "win-win" situations of a rural residents medical benefit,business income increase in fixed-point medical institutions and health development.With overall improvement of the rural health service level,the medical service problems in the township and village two basic medical and health institutions have attracted more and more research and policy attention.Whether the New rural cooperative medical system is operated normally,the key is to have a medical service system with good quality and cheap supply.At present,this medical service is mainly took on by the county, township,village three health services network.County level medical organization is primarily responsible for inpatients with disease diagnosis and emergency rescuing;Township Health Center is responsible for the provision of common disease, frequently-occurring disease diagnosis and treatment;Village clinics is in charge of the general disease diagnosis and treatment work within the scope of the administrative village.Three rural health services network should be effective for triage of patients in rural areas,so that most of the basic medical needs of rural residents are met in the basic medical institutions.However,because the allocation of medical resource between urban and rural exists a severe imbalance and inequity in our country and the township and village two medical service institutions generally face the difficulty that the human resources,technology and equipment construction are lagging behind the medical demands of rural residents,the township and village two medical service institutions cannot provide reliable service quality guarantee for the normal operation of new rural cooperative medical system,the farmers prefer county level hospital with long distance and high price,especially in the case of serious illness.Therefore, the current rural basic medical service institutions cannot provide reliable organizational guarantee for the normal operation of new rural cooperative medical system and also do not well realize the original intention of the new rural cooperative medical system to alleviate farmer poor access and high fee are.Rural basic medical service quality is directly related to the health of rural residents and the vital economic interests.Strengthening the construction and management of the township hospitals,village clinics service quality is the key link to consolidate and develop the rural cooperative medical at present and in the future.
This study attempts to analyse and make a summary of the current situation,problems and causes of rural basic medical service quality after the implementation of new rural cooperative medical system,based on the investigation of the township hospitals,village clinics service quality in some regions of China.In the meantime,the stakeholders theory and the governance theory are drawn into the research on rural basic medical service quality and from the stakeholder perspective,explore the strategy and measures of rural basic medical service quality improvement in order to provide a strong theoretical and practical basis for new rural cooperative medical system.
1. The contents
This dissertation is constituted by five parts.
Part I(Chapter one and two):Through the background analysis and literature review,the research problems are elucidated,including in main contents,basic ideas and main methods.The goverance practice and theory study related to the domestic and foreign medical service are reviewed and combed,thus forming the understanding of the health service quality issues,governance and stakeholder theory.
Part Ⅱ (Chapter three, four and five):Under the macroscopic background of the rural cooperative medical system change and the rural medical and health system reform,the production,development and realistic condition of rural medical and health system are explained.Using the double difference model,the effect of the rural cooperative medical system on the rural basic medical service pattern are investigated.Based on the economics analysis of rural medical and health service demand and supply,taking township hospitals and village clinics,which are the main base fixed medical institutions in the new rural cooperative medical,as the breakthrough point and using structural equation analysis etc,from both sides of supply and demand perspective,the main factors that affect the township hospitals and village clinics medical service quality are explored. By questionnaire and interview investigation of township hospitals and village clinics service quality in sample areas,combined with the national data published,the current situation,problems and causes of rural basic medical service quality are analysed and summarized after the implementation of new rural cooperative medical system.
Part Ⅲ(Chapter six and seven):Using the Delphi method,questionnaire and interview,et al,the stakeholders in the new rural cooperative medical service institutions are defined,classified and analysed of interest orientation and conflict and look for the condition and mechanism of collaborative management of the stakeholders.By analysis of negative feedback,positive feedback and delay structure,the stakeholders in the new rural cooperative medical service institutions are analyzed by medical service quality problem schema.Integrating the core stakeholders to government subsystem,rural medical and health institutions subsystem,patient subsystem,managers subsystem,new rural cooperative management subsystem and parmacy supplier subsystem,at the same time,making the system schema analysis by graphic structure,from the perspective of stakeholder,inquiry into the improvement strategy of rural basic medical service quality under the new rural cooperative medical system.
Part IV (Chapter eight):The collaborative management on the stakeholders in rural basic medical service quality under the new rural cooperative medical system are designed. According to the management goal,management structure and framework of management mechanism,clarify the process and mechanism of rural basic medical service quality governance under the new rural cooperative medical system. Constructing and using the utility model of collaborative management of rural basic medical service quality,deeply characterize the mechanism and the key point of the rural basic medical service quality governance and in the end,puts forward a new rural basic medical service quality management idea.
Part Ⅴ (Chapter nine):Summarize the research conclusion and put forward the corresponding policy recommendations and the prospect of a follow-up study.
2. The conclusions
(1)The new rural cooperative medical system brings development opportunity for rural basic medical service institutions,but also flings down a challenge to the basic medical service quality.The quality problems have become a bottleneck of the development of rural basic medical service institutions and an impediment to the effective operation of the new rural cooperative medical system.That the new rural cooperative medical system as a resource allocation mechanism adopts what kind of payment and the main payment flow has the profound influence on the the farmer's medical behavior and the designated medical institutions'service behavior.In this dissert,the double difference model analysis of the CHNS screening data shows that the new rural cooperative medical system improves the proportion of patients to the township hospital and makes more and more rural residents get medical treatment from the the rural basic medical institutions.Researchers have also found that rural basic medical service quality can not meet the needs of farmers. Though the county,ountryside,village three level medical health network layout has formed and the medical service accessibility of rural residents is better in rural areas, because the technology is poor in the rural township,village level two basic medical and health institutions,rural residents encountering a "serious " would rather spend choice of county-level hospitals,which cause the city hospital overcrowding and difficult to see a doctor and form the vicious spiral of equipment idle and brain drain in the basic hospital.
(2) Whether researchers or policy makers, are required to properly search of current rural basic medical service quality problems existed in rural basic level, the current medical service quality problems are mainly manifested in:low grade technology,drug abuse and non-standard diagnosis and treatment behavior etc.Under the framework of current rural cooperative medical system,through investigation and analysis from two aspects of supply and demand,township health centers (Supplier) attaches importance to medical services technical quality,including the rational use of drugs, clinical diagnosis standard and treatment quality,etc.The patients'(consumers') reaction to township health centers'quality problems mainly show in the doctor's level,equipment condition, occupation moral attitudes and medical expenditure,et al.At present,the village clinic (seller) pays close attention to the quality of diagnosis and treatment,sterilization,personnel quality etc,nevertheless,the patients'(consumers') reflection on village clinic quality problems are mainly in poor equipment condition and less types of drugs etc.The cause which Leads to service quality problems in the township health hospital are lack of medical technical personnel and missing in the internal quality management and external quality monitoring mechanism.The medical quality problems in village clinic appears more fuzzy.That the policy of construction and development in village health organization and personnel is not clear is the source which is the impact on the village clinic medical quality management.
(3)With the implementation of new rural cooperative medical system and the provision of rural medical and health service,there has been a tendency that government does everything.The policy do not take into account the interests of different groups,which influences the effects of initial goals and leads to the weak management and supervision in the basic medical services quality.The characteristics of medical health services,due to the public welfare nature,service supply monopoly and supply induction of medical service product itself,determine the consumers'willingness to pay and the service providers'supply desire.From the perspective of management,the government is designer and organizer of the new rural cooperative medical system.The implementation of new rural cooperative gives the changes from the simple doctor-patient relationship to the relationship among the government,medical institutions and farmers.The new rural cooperative medical system design make too much emphasis on the control of medical costs,while ignoring quality management of the fixed-point medical institutions,at the same time,the farmers are lack of effective supervision channels and complaint mechanism about medical service institution quality,in the end,which cause that the guarantee and improvement in the rural basic medical service quality is unable to be obtained.
(4)Under the policy framework of new rural cooperative medical, township health hospital and village clinic are special compound organization that provides basic medical and public health service.Because there are many stakeholders and there is a conflict of interest among different stakeholders, the coordination and integration of interests is the key of goverance of the rural basic medical service quality. The stakeholders in the rural basic medical service institutions are an individual or a group who make the investment in the network and take risks. According to the status and role of them, the stakeholders are divide into key,intermediate and borderline stakeholders.Due to the different stakeholder interests differences, stakeholders in the rural grassroots health network exist in the following kinds of conflicts of interest:the first,conflicts of interest among medical and health service; providers, consumers and their agents;Second, when the medical service target preferences and choice are inconsistent.the different stakeholders produce conflict of interest,such as governments at all levels and their functional departments,township health hospitals,new rural cooperative management office,village doctor and rural residents etc.These interest coordination and integration of conflicts is the Key Points of the rural basic medical service quality governance.
(5)The system schema analysis from the point of view of the different stakeholders explains the existing governance problems and reasons in the rural basic medical service.The rural basic medical service institutions transforms the emphasis and nature of medical and health work under the tide of "market".On the one hand, this "marketing" environment makes the relationship changes from the cooperation to competition between township health hospital and village clinic as the leading role of the rural basic medical service institutions, and decrease the overall quality of the rural basic medical service.On the other hand, along with the economic system reform,township health hospital and village clinic basically has become the independent of each other market main body.In order to recreate the rural basic medical service institutions orderliness and integrity, in the late1990s,20th century, country puts forward the "rural health administration integration" policy. The relationship between the current township health hospital and the village clinic, in essence, is that township health hospital manage village clinic by the commission of local governments. In the absence of ownership, the entrusted management is easy to produce illegal operation, strive for profits with village doctor and the unfair distribution of interests, which led to the erosion of goal of rural basic medical service institutions.
(6)The current rural basic medical service institutions drift and debate on the attributes of "public interest","welfare" and "nonprofit". The new cooperative medical system also get into a "supervision" and "do" ambiguous position. The key to break the rural basic medical service problems is the remodeling of quality supervision mechanism.①The implementation of the new rural cooperative medical treatment, in a certain degree, affects interest pattern of the rural basic medical service. Although the medical business orientation is different between township health hospitals and village clinic, there exists more intense competition relationship. Thus, under the framework of new rural cooperative medical service system,may carry out the internal integration for the rural basic medical service institutions and break the pattern of act of their own free will.Village doctor can serve as the new rural cooperative medical treatment,"gatekeeper" role.Through the first filtering,establish the referral system among village,township,county.②Because rural basic medical service institutions entrusted by the state public health administrative department,take on the public health service functions,the township health hospitals and village clinic can't develop towards the general hospital mode and clinic. The township-village integration management should be implemented.At the same time,based on the longitudinal business cooperation between the township health hospitals and village clinic,enact the quality supervision mechanism at different levels.
(7)As the special multi-level principal-agent relations in the design of new rural cooperative medical system,with the extension of medical and health services,each core stakeholders are treated during the internal governance of township,village level two medical service quality,including the governance structure of the doctor-patient relationship, hospital operation, and the new rural cooperative medical insurance link. Also may consider seting up the physical organization consisting of representatives of the core stakeholders under the guidance by the government and carrying out the objective, independent coordination and supervision on rural basic medical service. The focus of external governance is mainly a government external management platform to build and a market mechanism and the social supervision system to improve.
3. The innovations
(1) From the supply and demand perspective, the main problems about service quality are discovered more accurately in the township and village two basic medical institutions designated by the new rural cooperative system. By quantitative,qualitative analysis of the township hospitals and village clinics,this study find the township hospitals and village clinics (Suppliers) pay attention to the medical services technical quality,yet the patients'(consumers) reaction to the basic medica service quality problems mainly show in non-technical quality dimensions.The above findings provide an empirical basis and inspiration for the improvement of basic medical service quality.
(2)Put forward the ideas of rural basic medical service quality stakeholders collaborative governance. The existing research is unilateral governance from the perspective of the government or hospital. The stakeholders governance theory is introduced into this study on rural medical service quality under the new rural cooperative medical system.Counting the township hospitals and village clinics as a composite organization and according to the governance target of rural basic medical service quality system,the stakeholders collaborative governance objectives, structure and operation mechanism of the rural basic medical service quality are explored,which provide the decision-making reference for the government to improve and enhance the rural basic medical service quality.
本研究试图通过对我国部分地区乡镇卫生院和村卫生室医疗服务质量的调查研究,总结和分析新农合实施后农村基层医疗服务质量的现状、问题和根源。并将利益相关者和治理理论引入农村基层医疗服务质量研究领域,从利益相关者治理的视角探索农村基层医疗服务质量提升的策略和措施,为新农合成熟规范运行提供有力的理论和实践依据。
一、论文的研究内容
第一部分(第1章、第2章)：通过背景分析与文献研究回顾阐明研究的问题。包括选题的提出与选题的意义、研究的主要内容、基本思路和主要方法。回顾与梳理国内外医疗服务治理实践及相关理论研究,形成对医疗卫生服务质量问题、治理及利益相关者理论的认识。
第二部分(第3章、第4章、第5章)：在农村合作医疗制度变迁与农村医疗卫生体制改革的宏观背景下,阐述农村基层医疗卫生服务系统的产生、发展及其现实状态,运用双重差分模型探讨新农合政策对农村基层医疗服务格局的影响；在经济学视角分析农村医疗卫生服务需求与供给的基础上,以作为新型农村合作医疗主要基层定点医疗机构的乡镇卫生院和村卫生室为切入点,运用结构方程分析等定量方法从供需双方的角度探讨影响乡镇卫生院、村卫生室医疗服务质量的主要因素；通过样本地区乡镇卫生院和村卫生室服务质量的问卷及访谈调查,结合国家公布的数据资料,总结和分析新农合实施后农村基层医疗服务质量的现状、问题和根源。
第三部分(第6章、第7章)：运用德尔菲法、问卷及访谈等调查研究方法对新农合基层医疗服务机构的利益相关者进行界定、分类及利益取向、利益冲突分析,寻找利益相关者协同治理的条件与机制。通过正反馈、负反馈及延迟结构分析,围绕新农合基层医疗服务机构的核心利益相关者进行医疗质量问题基模分析。将众多的核心利益相关者整合为政府子系统、农村基层医疗卫生机构子系统、患者子系统、新农合管理者子系统和药品供应商子系统,采用图形结构进行系统基模分析,从利益相关者视角探讨新农合制度下农村基层医疗服务质量的改善策略。
第四部分(第8章)：展开新农合下农村基层医疗服务质量利益相关者协同治理设计。按照治理目标、治理结构、治理机制的结构框架来阐明新农合下农村基层医疗服务质量治理的过程与机制。构建农村基层医疗服务质量协同治理的效用模型,通过模型更为深入地刻画农村基层医疗服务质量治理的关键点与作用机制,提出全新的农村基层医疗服务质量的治理思路。
第五部分(第9章)：总结研究结论,提出相应的政策建议,并展望后续研究。
二、论文的主要结论
1、新型合作医疗制度给农村基层医疗服务机构带来了发展机遇的同时也对基层医疗服务质量提出了挑战,质量问题已成为农村基层医疗机构发展的瓶颈,也成为新农合有效运转的绊脚石。新农合本身作为一种资源配置的机制,采取何种付费方式以及主要的付费流向,对于农民的就医行为以及各定点医疗机构的服务行为,都有深刻的影响。本文通过对CHNS筛选数据的双重差分模型分析表明,新农合持续提高了患者到乡镇卫生院就诊比例,政策的实施使得农村居民的就医流向趋于基层医疗机构。我国农村地区基本形成了县、乡、村三级卫生网络布局,农村居民的医疗服务“可及性”较好,但是由于农村乡、村两级基层医疗卫生机构的技术水平较差,农村居民遇到“大病”宁愿舍近求远地选择县级及县级以上医院,导致城市医院拥挤、看病难,而农村基层医疗机构设备闲置、人才流失的恶性循环。
2、无论是研究者还是政策制定者,都需要正确找寻当前我国农村基层医疗服务中存在的质量问题,目前农村基层医疗服务质量问题主要表现在：技术水平较差、药物滥用和诊疗行为不规范的等方面。在当前农村合作医疗制度框架下,从供需两个角度的调查分析发现,乡镇卫生院(供方)比较重视医疗服务技术性质量,主要包括诊疗质量、合理用药、临床诊疗规范等内容；患者(需方)对乡镇卫生院质量问题的反映主要集中在医生诊疗水平、设备条件、职业道德态度、医疗费用等方面；村卫生室(供方)目前关注的主要有：诊疗质量、器械消毒、人员资质等内容；患者(需方)对村卫生室的主要质量问题反映在设备条件差、药品种类少等方面。乡镇卫生院医疗服务质量问题产生的原因主要表现在：医疗技术人员缺乏、内部有效质量管理和外部质量监控机制缺失；村卫生室医疗质量问题显得更为模糊,村卫生室机构的建设和发展政策不明朗是影响村卫生室医疗质量管理的根源问题。
3、新型农村合作医疗的实施和农村医疗卫生服务的提供,都出现政府“包揽一切,,的倾向,政策的制定并没有顾及不同群体的利益诉求,影响了医疗服务最初目标的实现,同时导致基层医疗服务质量管理与监督的无力。由于医疗服务产品本身的公益性、服务供给的垄断性和供给诱导性的特点,决定了消费者的支付意愿,同时也决定了服务提供者的供给意愿。从管理学的角度分析,政府是新农合的制度设计者与组织者,新农合的实施使原来简单的医患双方转变为政府、医疗机构和参合农民的三方关系。现行新农合的制度设计过多地强调医疗费用的控制而忽视了对定点医疗机构服务质量的监管,参合农民对医疗机构服务质量缺乏有效的监督渠道和投诉机制,导致农村基层医疗服务质量无法得到保证和改善。
4、医疗服务质量的治理实际上是对医疗服务机构的治理,在新型合作医疗的政策框架下,乡镇卫生院与村卫生室作为提供基本医疗服务和公共卫生服务的特殊复合型组织,其利益相关者众多且存在利益冲突,利益的协调与整合是农村基层医疗服务质量治理的关键。农村基层医疗服务机构的利益相关者是对医疗服务进行了“投资”,并承担医疗服务结果可能造成的风险的个人或群体。按照他们在医疗服务中的地位和作用不同,分为核心利益相关者、中间利益相关者和边缘利益相关者。由于不同利益相关者利益目标的差异性,存在着以下几种利益冲突：第一,医疗服务消费者与提供者及其代理人(医生)之间的利益冲突；第二,各级政府及其职能部门、新农合管理办公室、乡镇卫生院、村医及农村居民等利益相关者,在医疗服务目标的偏好及选择不一致时产生的利益冲突,这些冲突的协调是重要的治理着力点。
5、系统基模分析从不同利益相关者的角度解释了农村基层医疗服务现存的治理问题及原因。农村基层医疗卫生机构在“市场化”浪潮下转变了医疗卫生工作的重点和医疗卫生工作的性质。一方面,这种“市场化”的大环境让农村三级卫生网络中的主角——乡镇卫生院和村卫生室由层级间的协作关系变质为层级间的竞争关系,使农村基层医疗服务的纵向整合质量降低。另一方面,随着经济体制的变革,乡镇卫生院和村卫生室基本上已经成为相互独立的市场主体。为了重塑农村基层医疗卫生工作的秩序化和完整性,20世纪90年代后国家提出了“乡村卫生管理一体化”的政策。但是,当前的乡镇卫生院与村卫生室的关系,实质上是乡镇卫生院受地方政府的委托对村卫生室进行管理。这种委托管理在所有权缺失的情况下,容易产生违规操作、与村医争利以及利益分配不公平的问题,这些失范行为导致农村基层医疗服务的目标侵蚀。
6、当前农村基层医疗卫生机构在“公益”、“福利”、“非营利”等属性上飘移、争论,新型合作医疗管理机构也陷入“督”与“办”的含混境地,破解农村基层医疗服务质量问题的关键是质量监督机制的重塑。①新型农村合作医疗的推行,在一定程度上影响了农村基层医疗服务的利益格局。虽然乡镇卫生院与村卫生室之间的医疗业务定位不同但两者之间仍然存在较为激烈的竞争关系。因此,在新型农村合作医疗制度框架下,可逐步打破各自为政的格局。村医可充当新农合的“守门人”中色,通过首诊过滤,建立村、乡、县逐级转诊制度。②乡镇卫生院和村卫生室不能向一般的医院模式和诊所方向发展,因为乡镇卫生院和村卫生室还受国家卫生行政部门委托,承担了公共卫生服务的职能。建议落实农村基层医疗卫生的乡村一体化管理,在乡镇卫生院与村卫生室的纵向业务分工合作的基础上,制定不同层次的质量监督机制。
7、由于新农合制度设计中特殊的多层级委托—代理关系,在农村地区乡村两级医疗机构服务质量的内部治理中,各核心利益相关者随着医疗卫生服务的延伸环节进行质量的治理。包括医患关系的治理结构、医院运营的治理结构、新型农村合作医疗保险环节的治理结构。可以考虑在政府引导下设置由核心利益相关者代表组成的农村基层医疗服务质量治理的实体组织,对农村基层医疗服务进行客观、独立的第三方协调与监督。外部治理的重点则主要是政府外部治理平台的打造以及市场机制与社会监督机制的完善。
三、论文的创新之处
1、采用供需双方视角的分析,较为准确地发现了新农合乡村两级定点医疗机构服务质量的主要问题。通过对乡镇卫生院和村卫生室进行医疗服务质量的定量、定性分析,发现乡镇卫生院和村卫生室(供方)比较重视医疗服务技术性质量,而患者(需方)对基层医疗服务质量问题的反映则更倾向于非技术性质量维度,这为改善农村基层医疗服务质量提供了实证依据和启示。
2、提出了农村基层医疗服务质量利益相关者协同治理的思路。已有的治理研究多是政府或医院视角的单边治理,本研究将利益相关者与治理理论引入新农合农村基层医疗服务质量的研究领域,把乡镇卫生院和村卫生室作为特殊复合型组织,根据农村基层医疗服务质量体系的治理目标,探索了农村基层医疗服务质量利益相关者协同治理的目标、治理结构和运行机制,为政府改善和提高农村基层医疗服务质量提供决策参考。
This dissertation is a study on quality and governance for the rural basic medical service under the new rural cooperative medical system. The new rural cooperative medical policy to activate a large number of rural grassroots medical institutions,in fact enhanced township hospitals and village clinics in the status and role, especially the township hospitals which are the hub in the new rural cooperative medical system design and paid the unprecedented attention to by the government at the national level.With China's rapid development of rural health work, There appear the "win-win" situations of a rural residents medical benefit,business income increase in fixed-point medical institutions and health development.With overall improvement of the rural health service level,the medical service problems in the township and village two basic medical and health institutions have attracted more and more research and policy attention.Whether the New rural cooperative medical system is operated normally,the key is to have a medical service system with good quality and cheap supply.At present,this medical service is mainly took on by the county, township,village three health services network.County level medical organization is primarily responsible for inpatients with disease diagnosis and emergency rescuing;Township Health Center is responsible for the provision of common disease, frequently-occurring disease diagnosis and treatment;Village clinics is in charge of the general disease diagnosis and treatment work within the scope of the administrative village.Three rural health services network should be effective for triage of patients in rural areas,so that most of the basic medical needs of rural residents are met in the basic medical institutions.However,because the allocation of medical resource between urban and rural exists a severe imbalance and inequity in our country and the township and village two medical service institutions generally face the difficulty that the human resources,technology and equipment construction are lagging behind the medical demands of rural residents,the township and village two medical service institutions cannot provide reliable service quality guarantee for the normal operation of new rural cooperative medical system,the farmers prefer county level hospital with long distance and high price,especially in the case of serious illness.Therefore, the current rural basic medical service institutions cannot provide reliable organizational guarantee for the normal operation of new rural cooperative medical system and also do not well realize the original intention of the new rural cooperative medical system to alleviate farmer poor access and high fee are.Rural basic medical service quality is directly related to the health of rural residents and the vital economic interests.Strengthening the construction and management of the township hospitals,village clinics service quality is the key link to consolidate and develop the rural cooperative medical at present and in the future.
This study attempts to analyse and make a summary of the current situation,problems and causes of rural basic medical service quality after the implementation of new rural cooperative medical system,based on the investigation of the township hospitals,village clinics service quality in some regions of China.In the meantime,the stakeholders theory and the governance theory are drawn into the research on rural basic medical service quality and from the stakeholder perspective,explore the strategy and measures of rural basic medical service quality improvement in order to provide a strong theoretical and practical basis for new rural cooperative medical system.
1. The contents
This dissertation is constituted by five parts.
Part I(Chapter one and two):Through the background analysis and literature review,the research problems are elucidated,including in main contents,basic ideas and main methods.The goverance practice and theory study related to the domestic and foreign medical service are reviewed and combed,thus forming the understanding of the health service quality issues,governance and stakeholder theory.
Part Ⅱ (Chapter three, four and five):Under the macroscopic background of the rural cooperative medical system change and the rural medical and health system reform,the production,development and realistic condition of rural medical and health system are explained.Using the double difference model,the effect of the rural cooperative medical system on the rural basic medical service pattern are investigated.Based on the economics analysis of rural medical and health service demand and supply,taking township hospitals and village clinics,which are the main base fixed medical institutions in the new rural cooperative medical,as the breakthrough point and using structural equation analysis etc,from both sides of supply and demand perspective,the main factors that affect the township hospitals and village clinics medical service quality are explored. By questionnaire and interview investigation of township hospitals and village clinics service quality in sample areas,combined with the national data published,the current situation,problems and causes of rural basic medical service quality are analysed and summarized after the implementation of new rural cooperative medical system.
Part Ⅲ(Chapter six and seven):Using the Delphi method,questionnaire and interview,et al,the stakeholders in the new rural cooperative medical service institutions are defined,classified and analysed of interest orientation and conflict and look for the condition and mechanism of collaborative management of the stakeholders.By analysis of negative feedback,positive feedback and delay structure,the stakeholders in the new rural cooperative medical service institutions are analyzed by medical service quality problem schema.Integrating the core stakeholders to government subsystem,rural medical and health institutions subsystem,patient subsystem,managers subsystem,new rural cooperative management subsystem and parmacy supplier subsystem,at the same time,making the system schema analysis by graphic structure,from the perspective of stakeholder,inquiry into the improvement strategy of rural basic medical service quality under the new rural cooperative medical system.
Part IV (Chapter eight):The collaborative management on the stakeholders in rural basic medical service quality under the new rural cooperative medical system are designed. According to the management goal,management structure and framework of management mechanism,clarify the process and mechanism of rural basic medical service quality governance under the new rural cooperative medical system. Constructing and using the utility model of collaborative management of rural basic medical service quality,deeply characterize the mechanism and the key point of the rural basic medical service quality governance and in the end,puts forward a new rural basic medical service quality management idea.
Part Ⅴ (Chapter nine):Summarize the research conclusion and put forward the corresponding policy recommendations and the prospect of a follow-up study.
2. The conclusions
(1)The new rural cooperative medical system brings development opportunity for rural basic medical service institutions,but also flings down a challenge to the basic medical service quality.The quality problems have become a bottleneck of the development of rural basic medical service institutions and an impediment to the effective operation of the new rural cooperative medical system.That the new rural cooperative medical system as a resource allocation mechanism adopts what kind of payment and the main payment flow has the profound influence on the the farmer's medical behavior and the designated medical institutions'service behavior.In this dissert,the double difference model analysis of the CHNS screening data shows that the new rural cooperative medical system improves the proportion of patients to the township hospital and makes more and more rural residents get medical treatment from the the rural basic medical institutions.Researchers have also found that rural basic medical service quality can not meet the needs of farmers. Though the county,ountryside,village three level medical health network layout has formed and the medical service accessibility of rural residents is better in rural areas, because the technology is poor in the rural township,village level two basic medical and health institutions,rural residents encountering a "serious " would rather spend choice of county-level hospitals,which cause the city hospital overcrowding and difficult to see a doctor and form the vicious spiral of equipment idle and brain drain in the basic hospital.
(2) Whether researchers or policy makers, are required to properly search of current rural basic medical service quality problems existed in rural basic level, the current medical service quality problems are mainly manifested in:low grade technology,drug abuse and non-standard diagnosis and treatment behavior etc.Under the framework of current rural cooperative medical system,through investigation and analysis from two aspects of supply and demand,township health centers (Supplier) attaches importance to medical services technical quality,including the rational use of drugs, clinical diagnosis standard and treatment quality,etc.The patients'(consumers') reaction to township health centers'quality problems mainly show in the doctor's level,equipment condition, occupation moral attitudes and medical expenditure,et al.At present,the village clinic (seller) pays close attention to the quality of diagnosis and treatment,sterilization,personnel quality etc,nevertheless,the patients'(consumers') reflection on village clinic quality problems are mainly in poor equipment condition and less types of drugs etc.The cause which Leads to service quality problems in the township health hospital are lack of medical technical personnel and missing in the internal quality management and external quality monitoring mechanism.The medical quality problems in village clinic appears more fuzzy.That the policy of construction and development in village health organization and personnel is not clear is the source which is the impact on the village clinic medical quality management.
(3)With the implementation of new rural cooperative medical system and the provision of rural medical and health service,there has been a tendency that government does everything.The policy do not take into account the interests of different groups,which influences the effects of initial goals and leads to the weak management and supervision in the basic medical services quality.The characteristics of medical health services,due to the public welfare nature,service supply monopoly and supply induction of medical service product itself,determine the consumers'willingness to pay and the service providers'supply desire.From the perspective of management,the government is designer and organizer of the new rural cooperative medical system.The implementation of new rural cooperative gives the changes from the simple doctor-patient relationship to the relationship among the government,medical institutions and farmers.The new rural cooperative medical system design make too much emphasis on the control of medical costs,while ignoring quality management of the fixed-point medical institutions,at the same time,the farmers are lack of effective supervision channels and complaint mechanism about medical service institution quality,in the end,which cause that the guarantee and improvement in the rural basic medical service quality is unable to be obtained.
(4)Under the policy framework of new rural cooperative medical, township health hospital and village clinic are special compound organization that provides basic medical and public health service.Because there are many stakeholders and there is a conflict of interest among different stakeholders, the coordination and integration of interests is the key of goverance of the rural basic medical service quality. The stakeholders in the rural basic medical service institutions are an individual or a group who make the investment in the network and take risks. According to the status and role of them, the stakeholders are divide into key,intermediate and borderline stakeholders.Due to the different stakeholder interests differences, stakeholders in the rural grassroots health network exist in the following kinds of conflicts of interest:the first,conflicts of interest among medical and health service; providers, consumers and their agents;Second, when the medical service target preferences and choice are inconsistent.the different stakeholders produce conflict of interest,such as governments at all levels and their functional departments,township health hospitals,new rural cooperative management office,village doctor and rural residents etc.These interest coordination and integration of conflicts is the Key Points of the rural basic medical service quality governance.
(5)The system schema analysis from the point of view of the different stakeholders explains the existing governance problems and reasons in the rural basic medical service.The rural basic medical service institutions transforms the emphasis and nature of medical and health work under the tide of "market".On the one hand, this "marketing" environment makes the relationship changes from the cooperation to competition between township health hospital and village clinic as the leading role of the rural basic medical service institutions, and decrease the overall quality of the rural basic medical service.On the other hand, along with the economic system reform,township health hospital and village clinic basically has become the independent of each other market main body.In order to recreate the rural basic medical service institutions orderliness and integrity, in the late1990s,20th century, country puts forward the "rural health administration integration" policy. The relationship between the current township health hospital and the village clinic, in essence, is that township health hospital manage village clinic by the commission of local governments. In the absence of ownership, the entrusted management is easy to produce illegal operation, strive for profits with village doctor and the unfair distribution of interests, which led to the erosion of goal of rural basic medical service institutions.
(6)The current rural basic medical service institutions drift and debate on the attributes of "public interest","welfare" and "nonprofit". The new cooperative medical system also get into a "supervision" and "do" ambiguous position. The key to break the rural basic medical service problems is the remodeling of quality supervision mechanism.①The implementation of the new rural cooperative medical treatment, in a certain degree, affects interest pattern of the rural basic medical service. Although the medical business orientation is different between township health hospitals and village clinic, there exists more intense competition relationship. Thus, under the framework of new rural cooperative medical service system,may carry out the internal integration for the rural basic medical service institutions and break the pattern of act of their own free will.Village doctor can serve as the new rural cooperative medical treatment,"gatekeeper" role.Through the first filtering,establish the referral system among village,township,county.②Because rural basic medical service institutions entrusted by the state public health administrative department,take on the public health service functions,the township health hospitals and village clinic can't develop towards the general hospital mode and clinic. The township-village integration management should be implemented.At the same time,based on the longitudinal business cooperation between the township health hospitals and village clinic,enact the quality supervision mechanism at different levels.
(7)As the special multi-level principal-agent relations in the design of new rural cooperative medical system,with the extension of medical and health services,each core stakeholders are treated during the internal governance of township,village level two medical service quality,including the governance structure of the doctor-patient relationship, hospital operation, and the new rural cooperative medical insurance link. Also may consider seting up the physical organization consisting of representatives of the core stakeholders under the guidance by the government and carrying out the objective, independent coordination and supervision on rural basic medical service. The focus of external governance is mainly a government external management platform to build and a market mechanism and the social supervision system to improve.
3. The innovations
(1) From the supply and demand perspective, the main problems about service quality are discovered more accurately in the township and village two basic medical institutions designated by the new rural cooperative system. By quantitative,qualitative analysis of the township hospitals and village clinics,this study find the township hospitals and village clinics (Suppliers) pay attention to the medical services technical quality,yet the patients'(consumers) reaction to the basic medica service quality problems mainly show in non-technical quality dimensions.The above findings provide an empirical basis and inspiration for the improvement of basic medical service quality.
(2)Put forward the ideas of rural basic medical service quality stakeholders collaborative governance. The existing research is unilateral governance from the perspective of the government or hospital. The stakeholders governance theory is introduced into this study on rural medical service quality under the new rural cooperative medical system.Counting the township hospitals and village clinics as a composite organization and according to the governance target of rural basic medical service quality system,the stakeholders collaborative governance objectives, structure and operation mechanism of the rural basic medical service quality are explored,which provide the decision-making reference for the government to improve and enhance the rural basic medical service quality.
引文
①陈海峰,中国卫生保健史,上海科学技术出版社,1993,8
(?)卫生部《关于加强基层卫生组织领导的指示》,1957
①韩俊,中国农村医疗卫生状况报告,中国发展观察,2005(1)
①2008中国卫生服务调查研究—第四次家庭健康询问调查分析报告[M].北京：中国协和医科大学出版社.2009.12
①卫生部、财政部《关于建立新型农村合作医疗制度的意见(国办发20033号)》
②林闽钢,我国农村合作医疗制度治理结构的转型,农业经济问题,2006(5)
①杨燕绥、岳长等,医疗服务治理结构和运行机制,中国劳动社会保障出版社,2009.2(117)
①王凯,揭示降价药品潜规则,《大众日报》,2011.5.15
①王红漫,大国卫生之论,北京大学出版社,2006.4
①李维安,资本结构、公司治理和国有企业股份制改造,中国人民大学出版社,2002年4月(222)
①杨燕绥,岳公正等,医疗服务治理结构和运行机制,中国劳动社会保障出版社,2009.2
[1]艾尔·巴比.社会研究方法[M].北京：华夏出版社,2005.6.
[2]巴泽尔.产权的经济分析[M].费方域,段毅才译.上海：三联书店,1997：17-18.
[3]蔡立辉.医疗卫生服务的整合机制研究[J].中山大学学报(社会科学版),2010(1)：119-130.
[4]陈熬贵.乡镇卫生院管理体制存在的问题和改革措施[J].南京医科大学学报,2002(3)：222-225.
[5]陈洁主编.卫生技术评估[M].北京：人民卫生出版社,2008.
[6]陈林.非营利组织法人治理[M].洪叶出版社,2004.4.
[7]陈美琴.景宁畲族自治县农村卫生服务分析与探索[J].中国卫生经济,2009(9)：81-84.
[8]陈英耀.卫生服务评价.上海：复旦大学出版社,2007.
[9]程晋烽.中国公共卫生支出的绩效管理研究[M].北京：中国市场出版社,2008.
[10]程晓明,罗五金.卫生经济学[M].北京：人民卫生出版社,2003.
[11]崔颖,王蕾,阎升光,叶少东.乡镇卫生院功能发挥影响因素研究[J]现代预防医学,2007(10)：1922-1927.
[12]代志明,何洋.国外农村医疗保障制度的解读与借鉴[J].经济纵横,2005(2)：36.
[13]戴维·L·韦默.制度设计[M].上海：上海财经大学出版社,2004.
[14]邓国胜.论我国非营利组织的问责机制[J].中国行政管理,2003(3)：45-48.
[15]杜乐勋.关于国有医院产权制度转化与治理结构问题[J].中国医院管理,2003(7)：5-6.
[16]2008中国卫生服务调查研究—第四次家庭健康询问调查分析报告[M].北京：中国协和医科大学出版社,2009.
[17]樊继达.统筹城乡发展中的基本公共服务均等化[M].北京：中国财政经济出版社,2008：22-24.
[18]冯占春,熊占路.公立医院治理结构变革引入利益相关者理论的必要性分析[J].中国医院管理,2007,27(3)：11-12.
[19]高鉴国,高功敬.中国农村公共物品的社区供给机制[M].山东：山东人民出版社,2009：20-25.
[20]高培勇.公共部门经济学[M].北京：中国人民大学出版社,2001：26-37.
[21]高翔.我国医疗卫生物品供给的现实困境与治理对策一构建基于三元结构理论的协同型供给模式[J].湖北社会科学,2008(2)：71-74.
[22]葛智馨.我国部分农村地区乡村两级卫生机构卫生服务质量现状分析和指标体系设计研究.复旦大学硕士学位论文.2011.
[23]龚幼龙,冯学山.卫生服务研究.上海：复旦大学出版社,2002.
[24]顾金喜.社会公平合作体系与农村公共产品供给优化研究[D].浙江：浙江大学,2009：76.
[25]顾昕.全球性公立医院的法人治理模式变革——探寻国家监管与市场效率之间的平 衡[J].经济社会体制比较,2006(1)：46-55.
[26]顾昕.医疗卫生资源的合理配置：矫正政府与市场双失灵[J].国家行政学报,2006,3：39-43.
[27]顾听.走向有管理的市场化：中国医疗体制改革的战略性选择[J].经济社会体制比较,2005(6)：18-29.
[28]郭宏道.新型农村合作医疗内部控制构想.决策探索,2007,6：88-89.
[29]国务院发展研究中心课题组.对中国医疗卫生体制改革的评价与建议[R].北京：国务院发展研究中心,2005.
[30]韩俊,罗丹.中国农村卫生调查[M],上海远东出版社,2009.5.
[31]韩俊.中国农村医疗卫生状况报告[J],中国发展观察,2005(1)：22-24.
[32]韩子荣.中国城乡卫生服务公平性研究[M].北京：中国社会科学出版社,2009：151-189.
[33]何增科.公民社会与第三部门[M].北京：社会科学文献出版社,2000.259.
[34]贺雪峰：论农村公共物品供给中的均衡[J],经济学家,2006(1)：54-60.
[35]胡鞍钢,胡宇光.公司治理中外比较[C].北京：新华出版社,2004.
[36]胡鞍钢.卫生与发展：建设全民健康社会[M].北京：清华大学出版社,2004.
[37]胡琳琳,胡鞍钢.从不公平到更加公平的卫生发展：中国城乡疾病模式差距分析与建议[J].管理世界,2003(1)：78-87.
[38]胡善联.建设覆盖城乡居民的基本卫生保健制度的内涵和条件[J].中国卫生经济,2007(7)：8-10.
[39]黄锐,李塑,姜卫.医院药品双重垄断引起社会福利的损失探讨[J].医学与社会,2007,20(8)：22-24.
[40]黄锐.基于利益相关者的公立医院组织绩效评价指标体系研究[D].华中科技大学,2011.
[41]黄晓光.关于医院建立董事会制度及完善法人治理结构的思考[J].中国卫生经济,2003(7)：34-37.
[42]姜红玲.从医生费用控制视角谈社区卫生事业发展方向：基于英国全科医生制度的经济分析[J].中南财经政法大学研究生学报,2007(6).
[43]科斯等.契约经济学[M].北京：经济科学出版社,1999.
[44]李丙魁.政府主导下医疗体系的优化改革[J].理论界,2008(05)：181-182.
[45]李伯阳.农村基本医疗服务网络中的纵向连接性医疗服务质量链研究.华中科技大学博士学位论文.2012.
[46]李红霞.信息不对称理论之于医疗服务研究[J].医学与哲学,2005,26(7)：56-63.
[47]李丽.美国医疗服务规制的演进及启示[J].中国卫生经济,2008,27(6)：93-95.
[48]李玲,陈秋霖.新农村建设中的农村医疗卫生发展[J].中国党政干部论坛,2006,6)：16-20.
[49]李玲.改革开放背景下的我国医改30年[J].《中国卫生经济》,2008,27(2)：5-9.
[50]李鹏飞,汪德华,郑江淮.医疗服务价格管制与“以药养医”[J].南方经济,2006,8：68-76.
[51]李维安.资本结构、公司治理和国有企业股份制改造[M],中国人民大学出版社,2002,4 (222)
[52]李细建,廖进球.有限理性视角下的地方政府行为分析[J].社会科学家,2009,59(10)：44-47.
[53]李晓林.我国医疗服务领域公平性分析[D].吉林：吉林大学,2007.
[54]李燕凌,李立清新型农村合作医疗卫生资源利用绩效研究——基于倾向得分匹配法(PSM)的实证分析[J]农业经济问题2009(10)：67-73.
[55]李洋,王辉.利益相关者理论的动态发展与启示[J].现代财经,2004,24(7)：32-35.
[56]梁中堂.宏观视野下的我国医疗卫生体制改革[J].经济问题,2006(3)：12-17.
[57]林闽钢.我国农村合作医疗制度治理结构的转型[J],农业经济问题,2006(5)：34-39.
[58]刘聪,张亮,熊巨洋.乡镇卫生院评价的探索与启示[J].中国初级卫生保健,2006,20(8)：8-9.
[59]刘树新.构建我国以政府为主导的农村公共品供给的多中心模式[D].南京：暨南大学,2008：122-132.
[60]刘晓莉,金明华.基于服务质量差距模型的服务质量提升探讨.学术交流.2007.(09)：121-124.
[61]刘毅斌.环境管理信息系统的数据系统规范化研究.清华大学硕士学位论文.1994.
[62]刘有贵,蒋年云.委托代理理论述评[J].学术界,2006,(1)：69-78.
[63]楼苏萍.治理理论分析路径的差异与比较[J].中国行政管理,2005(04)：35-38.
[64]卢祖洵.社会医学.北京：科学技术出版社,2003.
[65]路冠军.均等化取向下的农村公共卫生服务体系构建—基于皖北三县的调查与分析[J].农村经济2007(11)：28-30.
[66]罗纳德·J·奥克森.治理地方公共经济[M].万鹏飞译.北京：北京大学出版社,2005：56-57.
[67]马骋宇,高静,于保荣,等.实施新型农村合作医疗制度对医疗机构反应性的影响研究[J].中国卫生经济,2010(7)：35-37.
[68]曼瑟尔·奥尔森.集体行动的逻辑(陈郁、郭宇峰、李崇新译)[M].上海人民出版社,1995：13.
[69]孟庆跃.医疗服务竞争：市场结构、竞争强度及其作用分析[J].中国卫生经济,2003,22(3)：44-53.
[70]苗卫军,陶红兵.对公立医院公益性的内涵及外延的分析[J].医学与社会,2009,22(4)：28-30.
[71]倪宗攒.医学统计学.北京：人民卫生出版社.2000.
[72]宁岩,任苒.合作医疗干预前后中国农村贫困地区乡镇卫生院服务效率比较[J].中国医院管理,2002(12).
[73]欧文·休斯.公共管理导论[M].北京：中国人民大学出版社,2001：90-91.
[74]裴淑敏,邓鹏翔.农村社区卫生管理现状分析和应对策略[J].中国公共卫生管理,2004(6)：68-74.
[75]青木昌彦,钱颖一.转轨经济中的治理结构：内部人控制和银行的作用[C].北京：中国经济出版社,1995.
[76]青木昌彦.比较制度分析[M].周黎安译.上海：上海远东出版社,2001.
[77]邱卫路.医疗服务质量管理研究综述.当代经济(下半月).2006.(10)：48-49.
[78]饶克勤,刘新明.国际医疗卫生体制改革与中国[M].北京：中国协和医科大学出版社,2006.
[79]任重远.医院治理模式改革的探索与实践[J]上海交通大学学报,2007(S1)：1-3.
[80]沙拉姆·赫斯马特.卫生管理经济学[M].北京：北京大学医学出版社,2004.
[81]邵德兴.新型农村合作医疗供给模式研究.上海交通大学博士学位论文.2006.
[82]舍曼,富兰德,艾伦.C.古德曼,迈伦.斯坦诺.卫生经济学[M].孟庆跃,王健译.北京：中国人民大学出版社,2004.15.
[83]沈蕾.医疗服务质量评价方法研究综述.消费经济.2006.(03)：55-59.
[84]盛亚.企业技术创新管理：利益相关者方法[M].北京：光明日报出版社,2009：68.
[85]世界卫生组织编.2008年世界卫生报告—初级卫生保健：过去重要现在更重要.兆瑞臻等译.北京：人民卫生出版社,2008：85-86.
[86]孙淑云.试论乡镇卫生院的功能与改革[J].中国农村经济,2005(11)：41-46.
[87]孙晓筠,A.Sleigh,李士雪,等.新型农村合作医疗对乡村医生处方行为的影响研究[J].中国卫生经济,2006,(4)：42-44.
[88]唐圣春,王贤吉,董鹏,合理用药相关利益集团分析[J].中国卫生经济,2007,26(7)：74-78.
[89]唐晓青,段桂江.面向全球化制造的协同质量链管理[J].中国质量,2002(9)：32-34.
[90]王红漫.大国卫生之论[M],北京大学出版社,2006.4.
[91]王凯.揭示降价药品潜规则[N].《大众日报》,2011.5.15.
[92]王克春,王小合.农村卫生事业理论与实践,北京：科学出版社,2009.
[93]王禄生,朱兆芳.论农村三级医疗卫生服务网络的组织管理[J].中国卫生政策研究,2009(4)：44-45.
[94]王淼淼,张翔,等.农村卫生服务网络中连续性服务存在的问题与对策[J].医学与社会,2011(4).
[95]王谦.城乡公共服务均等化问题研究[D].山东：山东大学,2008：88-96.
[96]王绍光.中国公共卫生的危机与转机[J].比较,2003(7)：52-88.
[97]王永莲,杨善发,黄正林.利益相关者分析方法在卫生政策改革中的应用[J].医学与哲学,2006(4)：27.
[98]魏杰,王韧.我国医疗服务体系的内在特性与改革思路[J].改革,2006(3)：109-115.
[99]温锐,陈胜祥.政府主导与农民主体的互动—以江西新农村建设调查分析为例[J].中国农村经济,2007(1)：37-44.
[100]吴吴.我国公立医院利益相关者治理模式构建研究—基于医药卫生体制改革的视角[D].重庆大学,2010.
[101]吴建.加强乡镇卫生院医疗质量控制的实践与体会[J].中国卫生事业管理,2006,4.
[102]吴敬琏.现代公司与企业改革[M].天津：天津人民出版社.1994.
[103]卫生部、财政部《关于建立新型农村合作医疗制度的意见(国办发20033号)》
[104]熊季霞,徐爱军.基于回归公益性的公立医院治理结构改革建议[J].中国卫生事业管 理,2010(11)：747-767.
[105]徐金发,常盛,谢宏.控制论视角的利益相关者分类[J].技术经济,2006,25(8)：103-105.
[106]徐喜荣.公立医院治理结构研究—一种法学的视角[J].中国卫生事业管理,2010(5)：297-299.
[107]徐小青,郭建军.中国农村公共服务改革与发展[M].北京：人民出版社,2008：46-58.
[108]徐壮飞.乡镇卫生院改制后的运行情况及对策[J].中国卫生政策,2002(8).
[109]杨立春.从委托代理理论看层级组织结构[J].现代管理科学,2004(1)：57-58.
[110]杨瑞龙.国有企业治理结构创新的经济学分析[M].北京：中国人民大学出版社,2001.
[111]杨善发,黄余送,王永莲,等.新型农村合作医疗政策利益相关者分析[J].中国农村卫生事业管理,2007(5)：323-326.
[112]杨团,施育晓.黄陵社区卫生服务体系改革的启示[J].中国卫生资源,2003(6)：259-262.
[113]杨秀琼.利益相关者的分类研究综述[J].阜阳师范学院学报(社会科学版),2009,(4)：58-61.
[114]杨燕绥,岳公正,杨丹.医疗服务治理结构和运行机制[M].中国劳动社会保障出版社,2009.
[115]姚岚,陈埙吹,刘运国.利用利益相关者理论分析我国农村医疗机构单病种定额付费[J].中国医院管理,2007,27(7)：22-24.
[116]于保荣.新型农村合作医疗制度进一步发展的瓶颈分析.医学与哲学(人文社会科学版).2008(29)：12：44-45.
[117]余央央,封进.收入差距与健康关系的研究评述[J].经济学动态,2006(7)：96.
[118]俞可平.治理与善治[M],社会科学出版社,2000.
[119]詹姆斯·M·布坎南.公共物品的需求与供给(马珺译)[M].上海：上海人民出版社2009：17.
[120]张传文.新型农村合作医疗制度可持续发展的思考.中国卫生事业管理.2009,5：337-338.
[121]张丹.影响医疗服务质量的非技术性因素研究.河南大学硕士学位论文.2010.
[122]张乐,袁庆,徐凌忠HACCP在新型农村合作医疗运行中的应用研究.中国卫生事业管理,2009,2：116-117.
[123]张里程,王禄生.我国农村合作医疗制度发展历史及其经验教训[J].中国卫生经济,1996,15(8)：14-15.
[124]张鹭鹭,胡善联,魏颖,等.论医院医疗服务供给的效率与公平[J].中华医院管理杂志,2000,16(5).
[125]张鹏.推进我国医疗卫生体制改革的对策[J].经济纵横,2009(4)：29-30.
[126]张维迎.博弈论与信息经济学[M],上海人民出版社,1996：12-26.
[127]张维迎.企业理论与中国企业改革[M].北京：北京大学出版社,1999.
[128]张跃平,刘荆敏.委托—代理激励理论实证研究综述[J].经济学动态,2003(6)：74-75
[129]张治国.农村贫困地区乡镇卫生院卫生服务质量改进策略和措施研究.华中科技大 学博士学位论文.2008.
[130]张智慧.中国医院经营状况调查[R].中国卫生产业,2005(02).
[131]章炜颖,安乾海.社区就诊患者满意度调查及影响因素分析.中国农村卫生事业管理,2008,(5)：346-348.
[132]赵成根.经济人假设在公共领域的适用性论析[J].中国行政管理,2006,(12)：91-96.
[133]郑颐.卫生保健质量过程评价和结果评价的比较[J].中国卫生质量管理,2005,12(1)：70-72.
[134]中共中央国务院关于深化医药卫生体制改革的意见[M].中国方正出版社,2009：44.
[135]朱玲.公办村级卫生室对保障基本医疗保健服务供给的作用[J].中国人口科学,2000(4).
[136]张琪,朱俊生中国医疗卫生服务与保障制度的整合研究[M].北京：中国劳动社会保障出版社,2009.5.
[137]周其涛.试论新型合作医疗制度[J].中国卫生事业管理.2003,10.
[138]周其仁.“政府主导”才是问题所在[N].经济观察报,2007.2.5.
[139]Abednego M.P.,Ogunlana S.O.Good project governance for proper risk allocation in Public-Private Partnerships in Indonesia[J].International Journal of Project Management, 2006,24(7):622-634.
[140]Alexander,Prekereds.Private Partiei Pation in Health Services.Washington,D.C. The WorldBank, PP.7-74.
[141]ArleenA.Leibowits.The demand for health and health concerns of 30years[J].Joumalof Health Eeonomics 23(2004)663-71.
[142]Barbara McPake,Francisico Jose YePes,Sally Lake et al.Is the colombian health system reform improving the performance of public hospital in bogot[J].Health Policy And planning:2003,18(2):182-194.
[143]Brekke K R,Sorgard L.Public versus private health care in a national health service[J]. Health Economies,2007,16(6):579-601.
[144]Chambers,Robert.The origins and practice of participatory rural appraisal[J].World development,1994,4 (7):953-969.
[145]Charles Collins,Andrew Green,David Her.Health sectorre for mand the interpretation Of Policy context[J],Health Policy47(1999)69-83.
[146]Devlin,N. P. Hansen,2001,"Health care spending and economic input:Granger causality." [J].Applied Economics, Vol 8,561-564.
[147]Food,C.M.International Health Care Reform:A Legal,Economic and Political Analvsis.London:Routledge,2000.
[148]Fuchs VR. Reflections on the socio-economic correlates of health[J].Journal of Health Economics,2004,23(4):653-661.
[149]Goldstien G,Healthy cities:overview of a WHO international program[J].Reviews on environmental health,2005,15:207-214.
[150]Grossman M. on the Concept of Health Capital and the Demand for Health[J].The Journal of Political Economy,1972,80(2):223-255.
[151]Grossman, Michael, "On the Concept of Health Capital and the Demand for Health,"Journal of Political Economy 80(1972b)223-255.
[152]Hurley, J, and R. Labelle(1995),"Relative fees and the utilization of physicians'services in Canada" [J].Health Economics 4:419-438.
[153]Israeli.Health Care System Following Reform[J].HealthPolicy,68(2):143-158.
[154]John R Griffith,Jeffrey A A1 expander,GailL Warden.Measuring comparative hospital Performanee/Praetitioner response[J]. Journal of Health care Management,2002,(47):1
[155]JohnCawley, Kosalil.Simon.Health in surance eoverage and the macroeeonomy [J].Journal Of Health Eeonomies 24(2005)299-315.
[156]Kanak Gautam.Transforming Hospital Board Meetings:Guide lines for Comprehensive Change[J].HOSPITALTOPICS:Researeh and Perspective son Health care,2005, 183(3):25-31.
[157]Kelley ET,ArisPel,HolmesJ.Beyond the initial in dieators:lessons from the OECD Health Care Quality In dieators Project and the US National Healtheare Quality RePort.Int JQual Health Care.2006.18SuPPll:45-51.
[158]Kerstin Kamke.The German Heaith Care System and Health Care Reform[J].Health Poliey43(1998):171-194.
[159]Laippala P., Nojonen K.. Development of a Patient-Orientated Instrument toMeasure Service Quality in OutpatientDe-partments[J].Journal of Advanced Nursing,2001,34 (4):696-705.
[160]LIH,Zhu Y.Income,income inequality,and health:Evidence from China[J].Journal of Comparative Economics,2006,34(4):668-693.
[161]LivioDiMatteo,The macro determinants of health expend iture in the United State and Canada:assessing the impact of income,age distribution and time[J]. Health Policy,2005,71(1):23-42.
[162]Luepker R.V.Community education for cardiovascular disease prevention:risk factor changes in the Minnesota Heart Health Program[J].American journal of public health, 1994,84:1383-1393.
[163]MareBerg,Yvomie Meijerink,MaritGras et al. Feasibility first:Developing Pub Performance indicators on Patient safety and clinical effectiveness for Dutch hospital [J].Health Policy,2005, (75):59-73.
[164]Marmot M.Wilkinson R.Social determinants of health.New York:Oxford University Press,1999.
[165]Morrow AL,Guerrero ML,Shults J,et all.Efficacy of home-based peer counselling to promote exclusive breastfeeding;a randomised controlled trial[J].Lancet,1999, 353:1226-1231.
[166]Nikkinen,Jussi,Sahlstron.Does agency theory Provide a general frame work for Audit Prieing[J].International Journal of Auditing,2004,8(11):253-262.
[167]Ogawa H.Healthy cities project in the Western Pacific.Tankano T.ED[J].Healthy cities and urban policy research,2003.
[168]Ourti,T. Measuring horizontal in equity in beglian health care using a Gaussian random effects two Part count model[J].Health Economics,2004,13:705-724.
[169]Paulette Snoby.Performanee improvement boot camp[J].Journal of radiology nursing, 2004, (23):68-70.
[170]Peterson T P.'Disruptive innovation'could change the health care landscape[J].MGMA Coimex,2005,5(2):5-12.
[171]Saltman,R.B.Figueras,J.&Sakellarides.Critical Challenges for Health Care Reform in Europe.Buckingham:Open University press,1998.
[172]Saowakontha S,Pongpaew P,Vudhivai N,et a11.Promotion of the health of rural women towards safe motherhood an intervention project in northeast Thailand[J].Southeast Asian Joumal of Tropical Medicine&Public Health,2000,31(2):5-211.
[173]Savedoff W D,Hussmann K.Why are Health Systems Prone to Corruption. In: Transparency International[J]. Global corruption report2006.London;AnnArbor,M1: Pluto Press/Transparency International,2006,4-14.
[174]Takano T.Development of healthy cities and need for research.London:Spon Press,2003
[175]Tilburt JC, Montori VM, Shah ND.What is value in health care? [J]. N Engl J Med,2011, 364(13):26-34.
[176]Turner J.R,Keegan A.E.Mechanism of governance in the project-based organization:a transaction cost perspective[J].European Management Journal,2001,19(3):254-67.
[177]Tyler Stitt,Evaluation of a Rural Sanitation Program Vanuatu with Management Recommendations[J]. Journal of Rural and TroPical Public Health,2005,(4):354-387.
[178]Victor Sower,JoAnn Duffy,William Kilbourne, etc.The Dimen-sions on Service Quality for Hospitals:Development and Use of the KQCAH Scale [J].HealthCare Management Review,2001,26(2):47-59.
[179]WHO.The World Health Report 2002:Reducing risks,promoting healthy life.Geneva:World Health Organization,2002.
[180]WHO.The world health report 2006:working together for health. Geneva:World Health Organization,2006.
[181]WHO.The world health rePort:Health system:ImProving Performance.Gene World Health Organization,2000.
(?)卫生部《关于加强基层卫生组织领导的指示》,1957
①韩俊,中国农村医疗卫生状况报告,中国发展观察,2005(1)
①2008中国卫生服务调查研究—第四次家庭健康询问调查分析报告[M].北京：中国协和医科大学出版社.2009.12
①卫生部、财政部《关于建立新型农村合作医疗制度的意见(国办发20033号)》
②林闽钢,我国农村合作医疗制度治理结构的转型,农业经济问题,2006(5)
①杨燕绥、岳长等,医疗服务治理结构和运行机制,中国劳动社会保障出版社,2009.2(117)
①王凯,揭示降价药品潜规则,《大众日报》,2011.5.15
①王红漫,大国卫生之论,北京大学出版社,2006.4
①李维安,资本结构、公司治理和国有企业股份制改造,中国人民大学出版社,2002年4月(222)
①杨燕绥,岳公正等,医疗服务治理结构和运行机制,中国劳动社会保障出版社,2009.2
[1]艾尔·巴比.社会研究方法[M].北京：华夏出版社,2005.6.
[2]巴泽尔.产权的经济分析[M].费方域,段毅才译.上海：三联书店,1997：17-18.
[3]蔡立辉.医疗卫生服务的整合机制研究[J].中山大学学报(社会科学版),2010(1)：119-130.
[4]陈熬贵.乡镇卫生院管理体制存在的问题和改革措施[J].南京医科大学学报,2002(3)：222-225.
[5]陈洁主编.卫生技术评估[M].北京：人民卫生出版社,2008.
[6]陈林.非营利组织法人治理[M].洪叶出版社,2004.4.
[7]陈美琴.景宁畲族自治县农村卫生服务分析与探索[J].中国卫生经济,2009(9)：81-84.
[8]陈英耀.卫生服务评价.上海：复旦大学出版社,2007.
[9]程晋烽.中国公共卫生支出的绩效管理研究[M].北京：中国市场出版社,2008.
[10]程晓明,罗五金.卫生经济学[M].北京：人民卫生出版社,2003.
[11]崔颖,王蕾,阎升光,叶少东.乡镇卫生院功能发挥影响因素研究[J]现代预防医学,2007(10)：1922-1927.
[12]代志明,何洋.国外农村医疗保障制度的解读与借鉴[J].经济纵横,2005(2)：36.
[13]戴维·L·韦默.制度设计[M].上海：上海财经大学出版社,2004.
[14]邓国胜.论我国非营利组织的问责机制[J].中国行政管理,2003(3)：45-48.
[15]杜乐勋.关于国有医院产权制度转化与治理结构问题[J].中国医院管理,2003(7)：5-6.
[16]2008中国卫生服务调查研究—第四次家庭健康询问调查分析报告[M].北京：中国协和医科大学出版社,2009.
[17]樊继达.统筹城乡发展中的基本公共服务均等化[M].北京：中国财政经济出版社,2008：22-24.
[18]冯占春,熊占路.公立医院治理结构变革引入利益相关者理论的必要性分析[J].中国医院管理,2007,27(3)：11-12.
[19]高鉴国,高功敬.中国农村公共物品的社区供给机制[M].山东：山东人民出版社,2009：20-25.
[20]高培勇.公共部门经济学[M].北京：中国人民大学出版社,2001：26-37.
[21]高翔.我国医疗卫生物品供给的现实困境与治理对策一构建基于三元结构理论的协同型供给模式[J].湖北社会科学,2008(2)：71-74.
[22]葛智馨.我国部分农村地区乡村两级卫生机构卫生服务质量现状分析和指标体系设计研究.复旦大学硕士学位论文.2011.
[23]龚幼龙,冯学山.卫生服务研究.上海：复旦大学出版社,2002.
[24]顾金喜.社会公平合作体系与农村公共产品供给优化研究[D].浙江：浙江大学,2009：76.
[25]顾昕.全球性公立医院的法人治理模式变革——探寻国家监管与市场效率之间的平 衡[J].经济社会体制比较,2006(1)：46-55.
[26]顾昕.医疗卫生资源的合理配置：矫正政府与市场双失灵[J].国家行政学报,2006,3：39-43.
[27]顾听.走向有管理的市场化：中国医疗体制改革的战略性选择[J].经济社会体制比较,2005(6)：18-29.
[28]郭宏道.新型农村合作医疗内部控制构想.决策探索,2007,6：88-89.
[29]国务院发展研究中心课题组.对中国医疗卫生体制改革的评价与建议[R].北京：国务院发展研究中心,2005.
[30]韩俊,罗丹.中国农村卫生调查[M],上海远东出版社,2009.5.
[31]韩俊.中国农村医疗卫生状况报告[J],中国发展观察,2005(1)：22-24.
[32]韩子荣.中国城乡卫生服务公平性研究[M].北京：中国社会科学出版社,2009：151-189.
[33]何增科.公民社会与第三部门[M].北京：社会科学文献出版社,2000.259.
[34]贺雪峰：论农村公共物品供给中的均衡[J],经济学家,2006(1)：54-60.
[35]胡鞍钢,胡宇光.公司治理中外比较[C].北京：新华出版社,2004.
[36]胡鞍钢.卫生与发展：建设全民健康社会[M].北京：清华大学出版社,2004.
[37]胡琳琳,胡鞍钢.从不公平到更加公平的卫生发展：中国城乡疾病模式差距分析与建议[J].管理世界,2003(1)：78-87.
[38]胡善联.建设覆盖城乡居民的基本卫生保健制度的内涵和条件[J].中国卫生经济,2007(7)：8-10.
[39]黄锐,李塑,姜卫.医院药品双重垄断引起社会福利的损失探讨[J].医学与社会,2007,20(8)：22-24.
[40]黄锐.基于利益相关者的公立医院组织绩效评价指标体系研究[D].华中科技大学,2011.
[41]黄晓光.关于医院建立董事会制度及完善法人治理结构的思考[J].中国卫生经济,2003(7)：34-37.
[42]姜红玲.从医生费用控制视角谈社区卫生事业发展方向：基于英国全科医生制度的经济分析[J].中南财经政法大学研究生学报,2007(6).
[43]科斯等.契约经济学[M].北京：经济科学出版社,1999.
[44]李丙魁.政府主导下医疗体系的优化改革[J].理论界,2008(05)：181-182.
[45]李伯阳.农村基本医疗服务网络中的纵向连接性医疗服务质量链研究.华中科技大学博士学位论文.2012.
[46]李红霞.信息不对称理论之于医疗服务研究[J].医学与哲学,2005,26(7)：56-63.
[47]李丽.美国医疗服务规制的演进及启示[J].中国卫生经济,2008,27(6)：93-95.
[48]李玲,陈秋霖.新农村建设中的农村医疗卫生发展[J].中国党政干部论坛,2006,6)：16-20.
[49]李玲.改革开放背景下的我国医改30年[J].《中国卫生经济》,2008,27(2)：5-9.
[50]李鹏飞,汪德华,郑江淮.医疗服务价格管制与“以药养医”[J].南方经济,2006,8：68-76.
[51]李维安.资本结构、公司治理和国有企业股份制改造[M],中国人民大学出版社,2002,4 (222)
[52]李细建,廖进球.有限理性视角下的地方政府行为分析[J].社会科学家,2009,59(10)：44-47.
[53]李晓林.我国医疗服务领域公平性分析[D].吉林：吉林大学,2007.
[54]李燕凌,李立清新型农村合作医疗卫生资源利用绩效研究——基于倾向得分匹配法(PSM)的实证分析[J]农业经济问题2009(10)：67-73.
[55]李洋,王辉.利益相关者理论的动态发展与启示[J].现代财经,2004,24(7)：32-35.
[56]梁中堂.宏观视野下的我国医疗卫生体制改革[J].经济问题,2006(3)：12-17.
[57]林闽钢.我国农村合作医疗制度治理结构的转型[J],农业经济问题,2006(5)：34-39.
[58]刘聪,张亮,熊巨洋.乡镇卫生院评价的探索与启示[J].中国初级卫生保健,2006,20(8)：8-9.
[59]刘树新.构建我国以政府为主导的农村公共品供给的多中心模式[D].南京：暨南大学,2008：122-132.
[60]刘晓莉,金明华.基于服务质量差距模型的服务质量提升探讨.学术交流.2007.(09)：121-124.
[61]刘毅斌.环境管理信息系统的数据系统规范化研究.清华大学硕士学位论文.1994.
[62]刘有贵,蒋年云.委托代理理论述评[J].学术界,2006,(1)：69-78.
[63]楼苏萍.治理理论分析路径的差异与比较[J].中国行政管理,2005(04)：35-38.
[64]卢祖洵.社会医学.北京：科学技术出版社,2003.
[65]路冠军.均等化取向下的农村公共卫生服务体系构建—基于皖北三县的调查与分析[J].农村经济2007(11)：28-30.
[66]罗纳德·J·奥克森.治理地方公共经济[M].万鹏飞译.北京：北京大学出版社,2005：56-57.
[67]马骋宇,高静,于保荣,等.实施新型农村合作医疗制度对医疗机构反应性的影响研究[J].中国卫生经济,2010(7)：35-37.
[68]曼瑟尔·奥尔森.集体行动的逻辑(陈郁、郭宇峰、李崇新译)[M].上海人民出版社,1995：13.
[69]孟庆跃.医疗服务竞争：市场结构、竞争强度及其作用分析[J].中国卫生经济,2003,22(3)：44-53.
[70]苗卫军,陶红兵.对公立医院公益性的内涵及外延的分析[J].医学与社会,2009,22(4)：28-30.
[71]倪宗攒.医学统计学.北京：人民卫生出版社.2000.
[72]宁岩,任苒.合作医疗干预前后中国农村贫困地区乡镇卫生院服务效率比较[J].中国医院管理,2002(12).
[73]欧文·休斯.公共管理导论[M].北京：中国人民大学出版社,2001：90-91.
[74]裴淑敏,邓鹏翔.农村社区卫生管理现状分析和应对策略[J].中国公共卫生管理,2004(6)：68-74.
[75]青木昌彦,钱颖一.转轨经济中的治理结构：内部人控制和银行的作用[C].北京：中国经济出版社,1995.
[76]青木昌彦.比较制度分析[M].周黎安译.上海：上海远东出版社,2001.
[77]邱卫路.医疗服务质量管理研究综述.当代经济(下半月).2006.(10)：48-49.
[78]饶克勤,刘新明.国际医疗卫生体制改革与中国[M].北京：中国协和医科大学出版社,2006.
[79]任重远.医院治理模式改革的探索与实践[J]上海交通大学学报,2007(S1)：1-3.
[80]沙拉姆·赫斯马特.卫生管理经济学[M].北京：北京大学医学出版社,2004.
[81]邵德兴.新型农村合作医疗供给模式研究.上海交通大学博士学位论文.2006.
[82]舍曼,富兰德,艾伦.C.古德曼,迈伦.斯坦诺.卫生经济学[M].孟庆跃,王健译.北京：中国人民大学出版社,2004.15.
[83]沈蕾.医疗服务质量评价方法研究综述.消费经济.2006.(03)：55-59.
[84]盛亚.企业技术创新管理：利益相关者方法[M].北京：光明日报出版社,2009：68.
[85]世界卫生组织编.2008年世界卫生报告—初级卫生保健：过去重要现在更重要.兆瑞臻等译.北京：人民卫生出版社,2008：85-86.
[86]孙淑云.试论乡镇卫生院的功能与改革[J].中国农村经济,2005(11)：41-46.
[87]孙晓筠,A.Sleigh,李士雪,等.新型农村合作医疗对乡村医生处方行为的影响研究[J].中国卫生经济,2006,(4)：42-44.
[88]唐圣春,王贤吉,董鹏,合理用药相关利益集团分析[J].中国卫生经济,2007,26(7)：74-78.
[89]唐晓青,段桂江.面向全球化制造的协同质量链管理[J].中国质量,2002(9)：32-34.
[90]王红漫.大国卫生之论[M],北京大学出版社,2006.4.
[91]王凯.揭示降价药品潜规则[N].《大众日报》,2011.5.15.
[92]王克春,王小合.农村卫生事业理论与实践,北京：科学出版社,2009.
[93]王禄生,朱兆芳.论农村三级医疗卫生服务网络的组织管理[J].中国卫生政策研究,2009(4)：44-45.
[94]王淼淼,张翔,等.农村卫生服务网络中连续性服务存在的问题与对策[J].医学与社会,2011(4).
[95]王谦.城乡公共服务均等化问题研究[D].山东：山东大学,2008：88-96.
[96]王绍光.中国公共卫生的危机与转机[J].比较,2003(7)：52-88.
[97]王永莲,杨善发,黄正林.利益相关者分析方法在卫生政策改革中的应用[J].医学与哲学,2006(4)：27.
[98]魏杰,王韧.我国医疗服务体系的内在特性与改革思路[J].改革,2006(3)：109-115.
[99]温锐,陈胜祥.政府主导与农民主体的互动—以江西新农村建设调查分析为例[J].中国农村经济,2007(1)：37-44.
[100]吴吴.我国公立医院利益相关者治理模式构建研究—基于医药卫生体制改革的视角[D].重庆大学,2010.
[101]吴建.加强乡镇卫生院医疗质量控制的实践与体会[J].中国卫生事业管理,2006,4.
[102]吴敬琏.现代公司与企业改革[M].天津：天津人民出版社.1994.
[103]卫生部、财政部《关于建立新型农村合作医疗制度的意见(国办发20033号)》
[104]熊季霞,徐爱军.基于回归公益性的公立医院治理结构改革建议[J].中国卫生事业管 理,2010(11)：747-767.
[105]徐金发,常盛,谢宏.控制论视角的利益相关者分类[J].技术经济,2006,25(8)：103-105.
[106]徐喜荣.公立医院治理结构研究—一种法学的视角[J].中国卫生事业管理,2010(5)：297-299.
[107]徐小青,郭建军.中国农村公共服务改革与发展[M].北京：人民出版社,2008：46-58.
[108]徐壮飞.乡镇卫生院改制后的运行情况及对策[J].中国卫生政策,2002(8).
[109]杨立春.从委托代理理论看层级组织结构[J].现代管理科学,2004(1)：57-58.
[110]杨瑞龙.国有企业治理结构创新的经济学分析[M].北京：中国人民大学出版社,2001.
[111]杨善发,黄余送,王永莲,等.新型农村合作医疗政策利益相关者分析[J].中国农村卫生事业管理,2007(5)：323-326.
[112]杨团,施育晓.黄陵社区卫生服务体系改革的启示[J].中国卫生资源,2003(6)：259-262.
[113]杨秀琼.利益相关者的分类研究综述[J].阜阳师范学院学报(社会科学版),2009,(4)：58-61.
[114]杨燕绥,岳公正,杨丹.医疗服务治理结构和运行机制[M].中国劳动社会保障出版社,2009.
[115]姚岚,陈埙吹,刘运国.利用利益相关者理论分析我国农村医疗机构单病种定额付费[J].中国医院管理,2007,27(7)：22-24.
[116]于保荣.新型农村合作医疗制度进一步发展的瓶颈分析.医学与哲学(人文社会科学版).2008(29)：12：44-45.
[117]余央央,封进.收入差距与健康关系的研究评述[J].经济学动态,2006(7)：96.
[118]俞可平.治理与善治[M],社会科学出版社,2000.
[119]詹姆斯·M·布坎南.公共物品的需求与供给(马珺译)[M].上海：上海人民出版社2009：17.
[120]张传文.新型农村合作医疗制度可持续发展的思考.中国卫生事业管理.2009,5：337-338.
[121]张丹.影响医疗服务质量的非技术性因素研究.河南大学硕士学位论文.2010.
[122]张乐,袁庆,徐凌忠HACCP在新型农村合作医疗运行中的应用研究.中国卫生事业管理,2009,2：116-117.
[123]张里程,王禄生.我国农村合作医疗制度发展历史及其经验教训[J].中国卫生经济,1996,15(8)：14-15.
[124]张鹭鹭,胡善联,魏颖,等.论医院医疗服务供给的效率与公平[J].中华医院管理杂志,2000,16(5).
[125]张鹏.推进我国医疗卫生体制改革的对策[J].经济纵横,2009(4)：29-30.
[126]张维迎.博弈论与信息经济学[M],上海人民出版社,1996：12-26.
[127]张维迎.企业理论与中国企业改革[M].北京：北京大学出版社,1999.
[128]张跃平,刘荆敏.委托—代理激励理论实证研究综述[J].经济学动态,2003(6)：74-75
[129]张治国.农村贫困地区乡镇卫生院卫生服务质量改进策略和措施研究.华中科技大 学博士学位论文.2008.
[130]张智慧.中国医院经营状况调查[R].中国卫生产业,2005(02).
[131]章炜颖,安乾海.社区就诊患者满意度调查及影响因素分析.中国农村卫生事业管理,2008,(5)：346-348.
[132]赵成根.经济人假设在公共领域的适用性论析[J].中国行政管理,2006,(12)：91-96.
[133]郑颐.卫生保健质量过程评价和结果评价的比较[J].中国卫生质量管理,2005,12(1)：70-72.
[134]中共中央国务院关于深化医药卫生体制改革的意见[M].中国方正出版社,2009：44.
[135]朱玲.公办村级卫生室对保障基本医疗保健服务供给的作用[J].中国人口科学,2000(4).
[136]张琪,朱俊生中国医疗卫生服务与保障制度的整合研究[M].北京：中国劳动社会保障出版社,2009.5.
[137]周其涛.试论新型合作医疗制度[J].中国卫生事业管理.2003,10.
[138]周其仁.“政府主导”才是问题所在[N].经济观察报,2007.2.5.
[139]Abednego M.P.,Ogunlana S.O.Good project governance for proper risk allocation in Public-Private Partnerships in Indonesia[J].International Journal of Project Management, 2006,24(7):622-634.
[140]Alexander,Prekereds.Private Partiei Pation in Health Services.Washington,D.C. The WorldBank, PP.7-74.
[141]ArleenA.Leibowits.The demand for health and health concerns of 30years[J].Joumalof Health Eeonomics 23(2004)663-71.
[142]Barbara McPake,Francisico Jose YePes,Sally Lake et al.Is the colombian health system reform improving the performance of public hospital in bogot[J].Health Policy And planning:2003,18(2):182-194.
[143]Brekke K R,Sorgard L.Public versus private health care in a national health service[J]. Health Economies,2007,16(6):579-601.
[144]Chambers,Robert.The origins and practice of participatory rural appraisal[J].World development,1994,4 (7):953-969.
[145]Charles Collins,Andrew Green,David Her.Health sectorre for mand the interpretation Of Policy context[J],Health Policy47(1999)69-83.
[146]Devlin,N. P. Hansen,2001,"Health care spending and economic input:Granger causality." [J].Applied Economics, Vol 8,561-564.
[147]Food,C.M.International Health Care Reform:A Legal,Economic and Political Analvsis.London:Routledge,2000.
[148]Fuchs VR. Reflections on the socio-economic correlates of health[J].Journal of Health Economics,2004,23(4):653-661.
[149]Goldstien G,Healthy cities:overview of a WHO international program[J].Reviews on environmental health,2005,15:207-214.
[150]Grossman M. on the Concept of Health Capital and the Demand for Health[J].The Journal of Political Economy,1972,80(2):223-255.
[151]Grossman, Michael, "On the Concept of Health Capital and the Demand for Health,"Journal of Political Economy 80(1972b)223-255.
[152]Hurley, J, and R. Labelle(1995),"Relative fees and the utilization of physicians'services in Canada" [J].Health Economics 4:419-438.
[153]Israeli.Health Care System Following Reform[J].HealthPolicy,68(2):143-158.
[154]John R Griffith,Jeffrey A A1 expander,GailL Warden.Measuring comparative hospital Performanee/Praetitioner response[J]. Journal of Health care Management,2002,(47):1
[155]JohnCawley, Kosalil.Simon.Health in surance eoverage and the macroeeonomy [J].Journal Of Health Eeonomies 24(2005)299-315.
[156]Kanak Gautam.Transforming Hospital Board Meetings:Guide lines for Comprehensive Change[J].HOSPITALTOPICS:Researeh and Perspective son Health care,2005, 183(3):25-31.
[157]Kelley ET,ArisPel,HolmesJ.Beyond the initial in dieators:lessons from the OECD Health Care Quality In dieators Project and the US National Healtheare Quality RePort.Int JQual Health Care.2006.18SuPPll:45-51.
[158]Kerstin Kamke.The German Heaith Care System and Health Care Reform[J].Health Poliey43(1998):171-194.
[159]Laippala P., Nojonen K.. Development of a Patient-Orientated Instrument toMeasure Service Quality in OutpatientDe-partments[J].Journal of Advanced Nursing,2001,34 (4):696-705.
[160]LIH,Zhu Y.Income,income inequality,and health:Evidence from China[J].Journal of Comparative Economics,2006,34(4):668-693.
[161]LivioDiMatteo,The macro determinants of health expend iture in the United State and Canada:assessing the impact of income,age distribution and time[J]. Health Policy,2005,71(1):23-42.
[162]Luepker R.V.Community education for cardiovascular disease prevention:risk factor changes in the Minnesota Heart Health Program[J].American journal of public health, 1994,84:1383-1393.
[163]MareBerg,Yvomie Meijerink,MaritGras et al. Feasibility first:Developing Pub Performance indicators on Patient safety and clinical effectiveness for Dutch hospital [J].Health Policy,2005, (75):59-73.
[164]Marmot M.Wilkinson R.Social determinants of health.New York:Oxford University Press,1999.
[165]Morrow AL,Guerrero ML,Shults J,et all.Efficacy of home-based peer counselling to promote exclusive breastfeeding;a randomised controlled trial[J].Lancet,1999, 353:1226-1231.
[166]Nikkinen,Jussi,Sahlstron.Does agency theory Provide a general frame work for Audit Prieing[J].International Journal of Auditing,2004,8(11):253-262.
[167]Ogawa H.Healthy cities project in the Western Pacific.Tankano T.ED[J].Healthy cities and urban policy research,2003.
[168]Ourti,T. Measuring horizontal in equity in beglian health care using a Gaussian random effects two Part count model[J].Health Economics,2004,13:705-724.
[169]Paulette Snoby.Performanee improvement boot camp[J].Journal of radiology nursing, 2004, (23):68-70.
[170]Peterson T P.'Disruptive innovation'could change the health care landscape[J].MGMA Coimex,2005,5(2):5-12.
[171]Saltman,R.B.Figueras,J.&Sakellarides.Critical Challenges for Health Care Reform in Europe.Buckingham:Open University press,1998.
[172]Saowakontha S,Pongpaew P,Vudhivai N,et a11.Promotion of the health of rural women towards safe motherhood an intervention project in northeast Thailand[J].Southeast Asian Joumal of Tropical Medicine&Public Health,2000,31(2):5-211.
[173]Savedoff W D,Hussmann K.Why are Health Systems Prone to Corruption. In: Transparency International[J]. Global corruption report2006.London;AnnArbor,M1: Pluto Press/Transparency International,2006,4-14.
[174]Takano T.Development of healthy cities and need for research.London:Spon Press,2003
[175]Tilburt JC, Montori VM, Shah ND.What is value in health care? [J]. N Engl J Med,2011, 364(13):26-34.
[176]Turner J.R,Keegan A.E.Mechanism of governance in the project-based organization:a transaction cost perspective[J].European Management Journal,2001,19(3):254-67.
[177]Tyler Stitt,Evaluation of a Rural Sanitation Program Vanuatu with Management Recommendations[J]. Journal of Rural and TroPical Public Health,2005,(4):354-387.
[178]Victor Sower,JoAnn Duffy,William Kilbourne, etc.The Dimen-sions on Service Quality for Hospitals:Development and Use of the KQCAH Scale [J].HealthCare Management Review,2001,26(2):47-59.
[179]WHO.The World Health Report 2002:Reducing risks,promoting healthy life.Geneva:World Health Organization,2002.
[180]WHO.The world health report 2006:working together for health. Geneva:World Health Organization,2006.
[181]WHO.The world health rePort:Health system:ImProving Performance.Gene World Health Organization,2000.