| 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 contentsThis 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. |
PDF Full Text Request