摘要
研究目的
本研究在“提出问题——分析问题——解决问题”的思路指导下,以湖北、江苏、河北三省的村卫生室为主要观察对象,收集了大量的原始数据,并在此基础上对村卫生室原先扮演的角色进行了深入分析,随后借助社会学、经济学、组织学的相关理论,结合卫生政策、区域卫生规划的情况以及国外卫生服务机构的经验,探讨村卫生室在新农村卫生服务体系中的理想角色模型及其支持系统,同时从管理和治理两大视角解答村卫生室角色定位应当如何实现。
研究方法
运用卫生经济学、卫生统计学和运筹学的理论,通过现场调查、信函调查和个人深度访谈收集数据,采用专家咨询、两步聚类法、TOPSIS综合评价法以及Bayes判别分析法对数据做进一步的处理,结合文献回顾、角色理论、路径依赖理论和治理理论的观点,为村卫生室的社会角色研究提供了强有力的支持。
研究结果
通过本研究的实际调查和理论分析,论证了村卫生室应有的作用与地位;分析了村卫生室自20世纪80年代以来角色失调现象产生的原因;在分析制度的路径依赖痕迹与我国卫生改革宏观形势的基础上,构建了新农村时期村卫生室的理想模型。模型中对村卫生室的举办形式以及如何扮演必要角色、基本角色和积极角色进行了详细地阐述,同时提出了该模型所需的支持系统,共同组建了一个完善的村卫生室运行体系。
为了使村卫生室的新角色能够成功扮演,不仅需要一个提供基础设施、人才供应以及财力、经费的支持系统,更需要政府合理、严谨地规划农村三级卫生网络的服务范围与程度,清楚地界定三者的职责,对村卫生室的机构设置、运作方式以及绩效考核制度进行改革,建立“闭环监督”机制。只有当制度变革和系统实施双管齐下,才能从根本上保障村卫生室角色朝着期望的方向转变。
研究结论
全文通过历史回顾和现状描述,遵循“理实交融”的原则,采取理论分析和实证研究相结合的方式,得出以下八个基本结论。
(1)村卫生室属于直线式管理的正式组织,职能是承担规定的疾病预防、妇幼保健、健康教育、残疾人康复等工作,提供常见病、多发病的一般诊治和转诊服务。
(2)村卫生室在新农村时期农村卫生服务体系中的作用与地位:公共卫生的“守门人”;农民健康的“保护伞”;医疗费用的“控制阀”;农村社会的“稳定器”。
(3)村卫生室在新农村时期的举办性质与形式:可以集体举办、村医联办,也可以个体承办,不管何种性质的产权与经营权形式,村卫生室应保持其非营利性、福利性的机构性质。
(4)当前村卫生室的角色混乱,与预设的角色定位存在分歧。造成这种现象的原因是国家和集体对村卫生室的投入不足、农村卫生改革滞后、卫生行政部门监管不利以及村卫生室自身的社会角色意识不足。
(5)找准村卫生室所要扮演的角色丛及其角色结构是解决村卫生室角色定位问题的先决条件。在理想角色模型中,村卫生室的社会角色由必要角色、基本角色和积极角色三个层次共同组成。其中,村卫生室的必要角色是公共卫生服务提供,基本角色是基本医疗服务,村卫生室的积极角色是对乡村社会的协调、健康发展有促进作用的相关行为。
(6)新农村时期村卫生室社会角色模型的支持系统:基本设施的支持与提供;人才供应与保障;财力、经费的投入与持续。
(7)新农村时期村卫生室社会角色的监督与考核机制:考核办法共分六个部份,医德医风(100分)、社区卫生服务管理(250分)、新型农村合作医疗管理(150分)、卫生防疫(250分)、资料管理(100分)、妇幼保健(150分)。
(8)管理视角和治理视角的政府改革是实现新农村环境下村卫生室角色定位的有力保障。在管理视角的改革中,根据村卫生室科学定位的总体框架,采用两步聚类法、TOPSIS综合评价法以及Bayes判别分析法等方法对村卫生室的社会角色进行定位,结合博弈论发现政府进行相关变革的必要性;在治理视角的改革中,通过对目前卫生系统中链式监督的弊端分析,得出只有建立闭环监督机制才能使农村卫生变革顺利进行的结论。
政策建议
为了密切配合村卫生室角色系统的运行,研究提出了适宜新农村时期的政策建议。
(1)村卫生室的房屋建设或使用应因地制宜。对于已经在使用并且达到国家要求的面积和功能分区的村卫生室,应区分其房屋所有权性质区别对待;对于没有村卫生室的行政村,或达不到国家要求的面积和功能分区的村卫生室,房屋应由县、乡政府统筹投入建设,所有权归村委会所有,房屋的维护、修缮等工作也由村委会承担,维修金由村委会向政府申请。
(2)村卫生室的基本设备应根据当地的经济与实际需要进行配备。对于已经在使用并且达到国家对基本设备要求的村卫生室,其设备无论是由政府或私人投入的,其所有权都应归国有,由乡镇卫生院进行管理,其中,设备由私人投入的应由县卫生局根据设备状况进行设备残值评估,政府出资购买,使其所有权转为国有;对于没有村卫生室的行政村,或达不到国家要求的村卫生室,村卫生室的基本设备应由国家和县卫生局负责投入,所有权归国有,由乡镇卫生院进行管理。
(3)村卫生室的药品配备应在《国家基本药物目录》、《乡村医生基本用药目录》,以及相关地方性规定的范围内进行药品种类、数量的配备。配备药品所需的经费来源应根据经营性质来定,如果是公营性质(村办、院办、村院联办)则应由村委会或乡镇卫生院出资,如果是私营性质(村医办)则经费由村医个人承担。
(4)农村卫生队伍应在用足用好存量的前提下,不断吸引增量。通过在村中寻找合适的替代者、由乡镇卫生院直接设点、动员正规医学院校的毕业生到村行医以及恢复大、中专医生的学历教育等方式保障村卫生室的人才供应;通过有计划、有考核的“闭环”培训方式提高乡村医生的综合素质和业务水平。
(5)政府在对卫生事业投入时应适当向农村倾斜,加大对农村卫生事业的支持力度。政府应从财力上支持公共卫生、基本医疗服务、人才培养等具有外溢效应的项目。
(6)村卫生室科学治理角度的政策倡导:政府应树立公平行政理念,积极组织与建立协商治理机制;吸收公民、社会团体加入公共决策过程;引入第三部门参与公共服务的供给;政府与卫生行政部门对卫生服务供给主体进行监管。
(7)政府应在新的方案基础上对机构设置、运作制度、绩效考核制度进行调整与变革,将链式监督制约机制转化为闭环监督制约机制,建立卫生机构与民众的良好互动,使改革得以切实有效地实施。
研究的创新与局限
1.研究的创新性
(1)运用社会角色理论,系统分析农村卫生服务体系中村卫生室,界定社会主义新农村时期村卫生室的社会角色期望,并对其内涵进行识别,构建村卫生室的角色模型,能够丰富和发展政府解决村卫生室经营、管理等方面的理论,提供认识村卫生室角色的新的政策思路,在当前的现实环境下具备较高的应用价值。
(2)本研究理论上提出村卫生室实现角色期望的途径和方法,并且着重探讨了社会转型期的村卫生室的社会支持系统,为农村卫生管理的实践模式提供政策及现实支持,从而保证村卫生室在农村卫生服务体系的作用得以顺利发挥。
2.研究的局限性
本研究在数据收集中由于条件局限,收集的数据样本相对要检验的命题而言是非常有限的,在指标设计的全面性及数据采集的科学性上还需要进一步探讨。同时,在有关村卫生室角色定位的研究中,从多理论视角探索是必要的,但笔者担心由于自身水平的限制对许多理论的理解不一定全面和深刻。
Objectives
Under the guidance of the idea of "posing the problems—analysising of the problems—solving the problems", this study has collected the massive primary data with the main object of observation of the village clinics in Hubei, Jiangsu and Hebei provinces. Based on those data, the study has carried on the depth Analysis of the role which acts originally to the village clinic, then, with the aid of sociological, economic, histology correlation theories, unioned health policy, region health plan situation and experience of overseas health Service organizations, discussed the ideal role model and support program of the village clinic in new rural sanitation services structure, as well as explained how can the role of village clinic location be realized from two great angles of view of management and government.
Methods
Under the theories of health economics, hygienic statistics and operations researches, this study made further processing of data, which was gained through spot investigation, correspondence investigation and individual depth interviews, by using the Delphi method, two steps cluster, the TOPSIS comprehensive evaluation as well as the Bayes Discriminate Analysis Method. The union of literature review, the role theories, the path dependence theory and the Governance Theory, has provided powerful support for the research on social role of village clinics.
Results
Through the studies' actual survey and the theoretical analysis, the research demonstrated the role and position the village clinics should be, analysised the reasons of the phenomena of disturbances of the role from the 1980s. Based on the trace analysis of path dependence and macroeconomic situation of health reform in our country, this study constructed an ideal model of village clinics in new rural period. In the model, there are detailed statements about what the holding form for village clinics should be and how to act the essential role, basic role and active role, meanwhile, the study puts forward the support system needed by the model and builds a perfect operational system for village clinics together.
In order to enable the new role of the village clinic to being acted successfully, a supporting system , which can provide the infrastructure and talented persons, support from the financial and funds resource, is necessary, and the government need plan the range of service and degree of countryside third-level health network reasonably and rigorously, limit their responsibilities clearly, reform organization's establishment, operation way as well as achievements system of examining and assessment of village clinic, and Establish closed loop supervising mechanism. Only when transformation and implementation of the system was employed by two methods to achieve one goal, can we security the roles of village clinic to transform fundamentally toward direction of our expectation.
Conclusions
Following "the principle really blends" principle, through historical review and description of the present situation, this article adopts in the way which the theoretical analysis and the empirical study was unified and draws the following eight basic conclusions.
(1) The village clinic belongs to the orthoscopic management official organization, whose function is to undertake stipulated works , such as the prophylaxis, mother and child care, health education, disabled persons' recovery, and provides diagnosis of common disease, frequently-occurring diseases and general the service of extension examines.
(2)During the period of new rural , the effect and positioning of social role of the village clinic must be "the porter" of the public health, "the protective umbrella" of the farmers' health, "control valve" of the medical expense and "stabler" of the rural community.
(3) During the period of new rural, the holding property and form of the village clinic: hold by collectivity, hold by collectivity and rural doctors or hold by private, no matter how the property right and management right is held, the village clinics should keep their property of non-profit and welfare. (4) Presently, the role of village clinics is chaotic and is different from the existed preinstall role localization. The reasons of this kind of phenomenon are that the investment from country and collective to village clinic is insufficient, the reform on rural sanitation is lag, the supervision of administration of public health department is disadvantageous and the consciousness of own social role of village clinics is insufficiency.
(5) The precondition of Solving localization question of social role of village clinic is to look for role which the accurate village clinic must act clump and role structure. In ideal role model, the social role of village clinics is composed by essential role, basic role and positive role. The essential role was provided by Public health service, the basic role was basic medical service, and the positive role was correlated behavior that could act promoting effect to coordinated and healthy development.
(6) The support system of social role model of village clinics during the new rural period: support and supply for the infrastructure, supply and ensure for personnel, launch and continue for finance and funds.
(7)Monitoring and evaluation mechanism for the social role of village clinics during the new rural period: six parts of check method, medical ethics and style(100 points), service and management of community health care(250 points) , management of New Rural Co-operative Medical System(150 points), hygiene and disease control (250 points ), data management (100 points), mother and child health care(150 points).
(8) The reform from government based on the view from the angle of management and government is the Powerful safeguard to realizes role localization of the village clinic under the new rural environment. Under the reform on the view from the angle of management we use two step cluster law, the TOPSIS quality synthetic evaluation law as well as the Bayes distinction analytic method to locate the social role of the village clinic based on science localization of overall frame of the village clinic, and discover the necessity of related transformation from government with game theory. Under the reform on the view from the angle of government, we draw the conclusion that, through the malpractice analysis to the present chain surveillance's sanitation system, only establishes closed loop supervising mechanism can carry on the transform of rural sanitation smoothly.
Suggestions
To coordinate closely role system of village clinic movement, this research proposed some policy suggestions which is suitable to the new countryside times.
(1) The houses construction or the use of village clinics should be acted as circumstances permit. We should treat the houses differently which were being used and met the national requirements in area and function district, for the administrative villages which were without the village clinics or did not meet the national requirements in area and function district, their houses should be constructed by county, township government through overall plan investment, and property right of the houses belongs to the village committee. So the village committee should do the job of maintenance and restoration, they could apply the maintenance cost to the government.
(2) The fundamental equipments for the village clinics should be acquired according to local economy and actual need. To those village clinics whose equipments were being used and met the national requirements, their equipments belonged to country, regardless of their investment come from government or personal, and their equipments should be managed by villages and towns public health center. And the equipments , which were invested by personal , the county health bureau should carry on the depreciation compensation according to equipment condition and make sure that they belonged to country. To those administrative villages that did not own village clinics or owned village clinics that did not meet the national requirements, their fundamental equipments should be invested by country and County health bureau, and their property right belonged to country , their equipments should be managed by villages and towns Public health center.
(3) Drugs equipment of village clinics should be accorded to stipulation from the laws of《Pharmaceuticals administration》,《contents of basic medication for Rural doctors》, including how to carry on equipment of the type, quantity of drugs according to range of local regulation. The funds for drugs equipment of village clinic should accord to nature of management. If it was public nature, like the village manages, the public health center to manage, the village and the public health center holds jointly, Village committee or Villages and township hospitals should invest. If not, the rural doctors should invest.
(4) Under the situation that rural sanitation troop was used fully, we should attracts the increase unceasingly. Through seeking for the appropriate replacer in the village, the Villages and towns Public health center supposed the spot directly, mobilized the regular medicine colleges and universities to practice medicine the graduate to the villages, restored the technical college, the specialized middle school doctor's school record education. By doing so, safeguard talented person supply for village clinics. In the planned, inspected closed loop training way, we could improve rural doctor's overall quality and the vocational level.
(5) When the government wants to invest to the public health, it should consider more for the rural, enlarge the support dynamics. The government should support the public health, the basic medical service, the personnel training financially which belong to the spill-over effect project, change the method that we carry on subsidy to the health agency differently just by Per capita, follow public finance's principle that we adjust the financial support points to public health, prevention health care, training of manpower in the way of the fixed quantity, decided an allocation and increases the finance transfer payment dynamics.
(6) Policy initiative for the village clinics in the science government angle: the governments should set up the fair administrative idea, organize and establish consultation government mechanism positively, absorb the citizen, the social group to join the public decision-making process, introduce the third department to participate in the collective services the supplies. And the government and the administration of public health department carry on the supervision to the hygienic service supplies main body.
(7) Based on the new plan, the government should make the adjustment and the transformation in the organization establishment, operation system, achievements system of examining and assessment, change chain type surveillance restricts the mechanism to restrict the mechanism for the closed loop surveillance, establish health agency and populace's good interaction enable the reform to implement effectively earnestly.
Creations and Limits
1. Creations
(1) Utilizing the theory of social role, following the systematical analysis of the village clinics which in the rural health system, defining the social role expectancy of village clinics in new socialist villages and recognizing its connotation, constructing the role model of village clinics, the article can enrich and develop the theories about how the government should solve the problems existing in business, management etc. in village clinics, it also supplies a new way of policy thinking for understanding the role of village clinics, which has more high applied value in current realistic situation.
(2) The research puts forward the ways and methods in theory to realize the role expectancy of village clinics, and focusing on the social support system of village clinics during the social transformation period, it provides policy and practical support for practical model of the rural health management, thus ensuring village clinics play their roles well in rural health service system.
2. Limits
With limited conditions in data collection, the collected data samples in the research are very limited compared with propositions to be examined, it also needs to be further investigated in comprehensiveness of the indicator design and scientific nature of the data acquisition. Meanwhile, in the role positioning of village clinics, it is necessary to explore from several theoretical angles, but confined by the knowledge of the writer, many theories could not be comprehended overall and deeply.
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