论文下载，下载下来可不是把论文里边的名字换成你的就行了哦，这样是不对的哦,亲，一定要自己创作哦，要是不会写论文。多读读别人的吧。

【摘要】 改革开放以来,我国在经济领域引入市场机制的过程中,在医疗卫生领域也逐步向市场化方向发展。在政府和市场定位不清,相互之间既缺位又越位的情况下,有关部门大力推行医疗卫生领域的市场化改革。结果是公共医疗保障覆盖面萎缩和医疗公平性、可及性受到损害,公共医疗保障机制脆弱和政府作用下降,医疗成本超常增长、医疗费用虚高和医疗败德行为缺乏有效约束、医疗市场混乱和医、患矛盾突出,政府改革公共医疗卫生路径出现偏差,公民健康保障的外部环境恶化等问题已成为构建和谐社会的一大顽症。面对当前我国公共医疗卫生改革的困境,有一种观点认为,产生问题的主要根源是医疗卫生领域的市场化不彻底,因此,应进一步加快医疗卫生的市场化改革,让市场机制在医疗卫生领域充分发挥作用,从而摆脱目前的困境。医疗卫生领域能否按市场化的改革思路进一步发展?市场化是否是解决目前突出的种种医疗卫生问题的“灵丹妙药”?本文通过理论和现实的分析研究,得出与之不同的观点。全文主要分为五章,其主要内容和基本观点如下:第一章,医疗卫生与政府干预的理论分析。本章主要分为二部分,一是从理论上论证医疗卫生服务能否按照市场规则充分提供。二是论证医疗卫生保障与经济社会发展之间的辨证关系。第一部分主要讨论和分析的内容有,根据医疗卫生服务的内容和经济特点,可将其分为公共品性质的医疗卫生服务、准公共品性质的医疗卫生服务和私人品性质的医疗卫生服务。首先分析了公共品性质的医疗卫生服务存在的市场失灵的现象和原因,因此,结论是这部分公共品性质的医疗卫生服务主要应当由政府提供。其次,讨论了主要与公民生存与发展密切相关的具有准公共品性质的基本医疗服务。基本医疗服务由于也存在严重的市场失灵,如供给者或医生出于经济利益考虑诱导医疗需求;消费者出于经济利益考虑逆向选择导致自愿参与的医疗保险市场消失,以及道德风险诱发过多的医疗需求;由于医疗服务存在着相当大的信息不对称和信息不完全性,以及医疗服务效果常具有的风险性和不可预见性,使得医疗服务具有天然的垄断性和特殊性,从而导致一般市场的价格机制失灵。这就要求公共部门即政府对其进行强有力的干预和建立健全基本医疗保障制度。在本章第二部分论证了医疗卫生保障与经济社会发展之间的相辅相成、互相促进的辨证关系。公共医疗卫生保障制度的完善会改变公民的消费预期和消费倾向,从而影响经济增长与社会发展。公共医疗卫生保障完善→消费需求稳定增长→经济稳定增长→社会和谐发展。因此,构建完善的公共医疗卫生保障制度是建立和谐社会的必然要求。第二章,公共医疗卫生保障制度改革的国际比较与启示。在实行市场经济的发达国家,从19世纪末期到20世纪中期,先后陆续形成了范围和程度不同的社会公共医疗保障制度。这其中的原因,如前所述主要是因为市场机制在医疗卫生领域存在的局限性和经济、社会发展的客观要求。因此,在医疗卫生这个特殊的领域,发达国家最终都对其进行程度不同的政府管制甚至于直接由政府提供。比如,在大多数发达国家目前都实行普遍覆盖、相对公平的社会医疗卫生保障制度,而对贫困人口医疗保障的全面覆盖则是发达国家不同医疗保障模式发展的共同特点。由于绝大部分发达国家的医疗保障普遍覆盖和医疗费用负担相对公平,社会医疗卫生保障制度已成为这些国家稳定社会的重要因素。美国是目前没有实施全民社会医疗保障制度仅有的两个工业化国家之一。美国受传统文化影响,崇尚市场和个人选择。因此,美国医疗保障整个体系主要是建立在市场化基础上。但医疗卫生领域固有的市场失灵,使美国以市场化为基础的医疗保障制度陷入困境。由于美国一开始没有建立全民覆盖的医疗保险制度,形成了不同的利益团体,致使全民社会医保在美国一直争论不休。没有全民社会健康保险制度,既导致了美国的医药费相对和绝对指标成为全球最高和最多,但同时医疗卫生效益却相对较差。这些对我国的启示是:下一步我国的医疗保障改革应朝着建立全民社会医疗保障制度发展。同时,也要认识到全民覆盖的社会医疗保障制度也有负作用,需要通过恰当的公共管理制度安排趋利避害,把负作用减少到最低限度,这就对政府的公共管理水平提出了挑战。英美国家的公共卫生管理,政府给予高度重视,具有较完备的法律体系和运作机制。公共卫生由统一的机构管理,政府管理部门责任明确,涉及到的各部门反映迅速、通力合作和各司其职。这些对我国的启示是:政府应设立统一的公共卫生管理协调机构。第三章,新中国公共医疗卫生保障制度的回顾与反思。从1952-1982年的30年间,在国家财力不强因而总体医疗卫生投入不高的情况下,我国人均预期寿命由35岁提高到68岁,婴儿死亡率由250‰降低到40‰,疟疾的发病率由5.5%降低到0.3%。应该说,在刚解放时,中国人民的健康指标属于世界上最低水平的国别组,而到20世纪70年代末,中国已成为拥有全面医疗保障体系的国家之一,80%-85%的人口享有基本医疗保健,并因此赢得国际社会的广泛赞誉。改革开放前我国政府主导的医疗卫生保障事业符合客观规律,我国政府在这个时期干预医疗卫生事业的路径选择符合客观规律。把公共卫生、尤其是传染病、常见病、多发病、地方病和基本医疗作为重点支持医疗卫生项目符合客观规律。普遍覆盖的医疗保障制度符合客观规律。公费医疗保障制度覆盖了行政事业单位的工作人员;劳保医疗保障制度覆盖了城镇职工及其家属,农村合作医疗组织在高潮时期覆盖面达到90%以上的农村。改革开放以来,我国在经济领域引入市场机制,同时在医疗卫生领域也进行了市场化改革。结果是政府和社会更多地放弃了公共责任,“减轻政府和企业负担”成为第一目标。在医疗卫生市场化的改革思路下,政府把医疗卫生事业包袱甩给了市场,医疗卫生机构和企业在生存的压力和牟利动机的驱使下,也放弃了必要的社会责任。结果导致应该是需要公共部门统一组织才能完成的公共卫生项目,因无利可图变成无人真正负责甚至变成了牟利的手段。在理论已经证明存在明显市场失灵的医疗卫生领域,政府和社会责任淡化,把基本医疗看成了私人品放手让市场提供。医疗卫生事业演变成了盈利性行业,医、药成为创收的机器和GDP增长的亮点,形成了一系列不合理的明规则和潜规则。在政府推卸包袱、医疗卫生机构和企业放弃社会责任的情况下,社会医疗保障覆盖面迅速萎缩、医疗(药)费用快速增长,人民群众看病难和看病贵的问题日趋严重。公共医疗卫生保障制度改革路径选择上出现失误,使我国的医疗卫生保障体系变成了主要由患者自付的医疗卫生体系。这就从根本上背离了社会医疗卫生保障制度的基本目标。此外,社会公众健康保障的外部环境不容乐观,公共卫生面临严峻挑战。第四章,我国公共医疗卫生保障制度改革思路。面对改革开放以来我国医疗卫生保障制度改革出现的困境,中央政府和理论界高度重视,积极寻求新的改革思路及对策。目前对于今后我国的医疗卫生保障制度改革,主要出现了两种思路。第一种改革思路是重新确立以政府为主导的医疗卫生保障事业。第二种改革思路是建议把医疗和卫生分开,公共卫生领域由政府承当,在医疗领域进一步朝着市场化方向改革。第二种思路的集中表现是宿迁医改。从我国和国际上的经验教训来看,第二种市场化改革思路违背了医疗卫生事业发展的基本规律,这样的改革思路将把我国的医疗卫生改革带入更大的误区之中。中央政府在反思改革开放以来我国医疗卫生领域推行市场化改革所导致的看病难和看病贵的深刻教训后,重新确立了以政府为主导的医疗卫生事业发展,以及建立覆盖城乡居民的基本卫生保障制度的思路。为了具体落实这一大思路,我根据中国的现实状况提出了建立我国公共医疗保障模式“两步走”的设想。第一步是建立城乡复式全民社会医疗保障改革模式;第二步是建立城乡统一的全民医疗保障改革模式。在改革和完善城乡复式全民社会医疗保障模式过程中,要考虑到与今后要建立的城乡统一的全民医疗保障改革模式的兼容性,同时要逐步向城乡统一的全民医疗保障改革模式逼近。对于纯公共品性质和外部性很大的健康保障项目,主要是公共卫生。首先要建立健全公共卫生预防制度。广义的公共卫生应当包括直接的公共卫生和间接的公共卫生。建立广义的健康保障公共卫生管理协调组织、公共卫生经费来源机制、公共卫生经费的使用机制和经费使用结果的监督和评估机制。第五章,城乡复式全民社会医疗保障制度。要实现城乡复式全民社会医疗保障制度的改革目标,首要的问题是如何保持全民社会医疗保障制度的有效运作以及财力的可行性和经费如何保障。通过对2004年和2005年全国卫生费收支测算表明,只要制度设计合理和公共管理到位,按现有的筹款方式和水平是可以建立起全民社会医保制度的,实行全民社会医保不会增加比现有医疗负担更多的负担。通过对2004年和2005年广州市医疗卫生费收支测算也表明,在经济发展较好的地区进行全民社会医保,经费已不是制约因素,主要的制约应是公共管理水平。因此,可先行试点,总结经验,力求使全民社会医疗保障制度发挥出应有的功能作用。考虑到基本医疗卫生保障是公民的必需品,要有可靠稳定的财力保障。为此,本章设计了全民社会医保制度下的医保税制。为了保持全民社会医疗保障制度的有效运作,本章还研究分析了医疗需求方、供给方和支付方的制度安排。在全民社会医疗保障模式下,关于医疗需求方的制度安排是,应当建立起有效的转诊制,以“守门人”制度抑制需求方的过度医疗需求。关于供给方和支付方的制度安排是,医疗服务供给方不再与医疗(药)的收入挂钩,利益诱因不在于推高医疗(药)成本来提高其自身收入。建议设置全民社会医疗保障管理委员会作为支付方的权力机关。全民社会医疗保障管理委员会以公共利益最大化为目标,凭借其掌握的资源控制和调节医疗供给方,通过全方位运筹,做出整体预算。全民社会医疗保障管理委员会代表公众选择质优价廉的医疗供给方,运用定性和定量分析的方法科学评价各类医疗供给方。同时要完善对全民社会医疗保障管理委员会的监督激励机制,从制度上保证全民社会医疗保障管理委员会不偏离公共利益。本章最后还研究了贫困人口健康保障问题。本文在目前国内外已有的研究基础上,通过对公共医疗卫生保障制度问题的进一步深入研究,在以下几个方面做出一些创新:1.设计了我国覆盖全体公民的“两步走”的全民社会医疗保障模式。(1)城乡复式全民社会医疗保障模式。该模式有A和B两大部分组成,A部分是城镇全民社会医疗保障模式,B部分是农村全民社会医疗保障模式。A、B下面设具有差异性的子部分且都含医疗救助。B部分中把自愿参加农村合作医疗改为强制参加,农村实行定额医保税。(2)城乡统一的全民医疗保障模式,即把城乡复式全民医保模式A和B合二为一。只要是中国公民都应享受统一标准执行的社会医疗保障体系。2.拓展了公共卫生的内涵。外部性尤其是负外部性在现代社会的愈演愈烈,原来狭义的公共卫生含义及其以此所制定的一系列公共卫生政策已经不适应形势发展的需要。世界各国把更多的注意力集中在医疗卫生支出方面,而医疗卫生保障的最终目的是公民的健康。良好的外部环境对公民健康保障作用会更大,从而跳出“健康→医疗”的狭隘范畴。只有创造一个良好的外部环境,以人为本也就是以公民的健康为本拓宽公共卫生的含义,才能使人民的健康依托在坚实的基石上。为此,本文拓展了公共卫生的内涵,提出了广义公共卫生的概念,它具体包涵了直接的公共卫生和间接的公共卫生,并以此提出了相应的政策建议。3.从国际比较中得出建立全民社会医疗保障制度。通过对国外的医疗卫生系统分析可以看出,美国和加拿大在20世纪70年代前两国的医疗卫生制度的发展很相似。1971年,两国的医疗卫生支出都占GDP的7.5%左右。但1971年以后,两国的医疗卫生制度开始向不同的方向发展。加拿大建立起了主要通过社会筹资的国家全民健康保险制度,而美国则基本维持原状。结果是美国的医疗卫生费用增长速度很快,但同时又有相当部分的人群未能享受公共医疗保险,成为发达国家中医疗卫生费用最高但效益最差的国家。美国以市场化为基础的松散的第三方支付制度没有能够、也不可能有效地发挥控制医疗费的作用。相反,美国没有全民社会医保,造成医保体系分割和无序,市场化为基础的松散的第三方支付制度却造成了医疗需求方和医疗供给方双方都没有节约医疗卫生资源的动机。从药品和医疗设备的生产到使用过度和新技术开发的过度以及医疗供给方诱导医疗需求变为常态。因此,我国的医疗保障制度改革应当吸取这一教训。4.提出了增进贫困人口健康保障的财政投入路径选择。对贫困人口健康保障的财政支出项目应排序,根据财力状况逐步推进。实证研究发现,在贫困人口健康保障中,药品和医疗手段并非起了关键的作用,而营养状况的改善则作用更大。因此,政府对贫困人口健康保障路径选择是:对贫困人口发放维持生存和发展的免费食品劵→改善贫困人口的健康状况，对贫困人口发放政府医疗劵→改善贫困人口的医疗卫生状况。5.设计了专用医保税制和全民社会医疗管理委员会的运作机制。基本医疗是准公共品,若依靠一般税收提供,不符合一般税收使用的原理,更主要的是我国财力也有限。若完全通过市场提供,又存在严重的市场失灵。因此,本文设计了专用医保税制。关于全民社会医疗管理委员会运作机制的核心主要是通过全民社会医疗管理委员会控制管理和约束医疗组织、医院、医生等的行为,以达到提高医疗卫生服务水平和质量,同时又控制医疗成本的目的。即通过对纳入政府预算的管理医疗组织、医院等实行总额预算和对其医生实行政府雇员制,其收入同看病治疗费用不挂钩,实行收支两条线,同时全民社会医疗管理委员会要对其制定科学的评价指标体系,运用定性和定量分析的方法科学评价,并将评价结果与经费拨款相对应,从而建立起责权利相统一的激励约束机制。

【Abstract】 Since the reform and opening policy in China, our medical treatment and sanitation field has developed into the direction of marketability step by step during the course of introducing market mechanism to China. The concerning organiations greatly promote the reform of its system’s marketability under the circumstances of vague orientation, the lack of orientation and offside between the government and market. The results are the problems which have become a serious cancer in building a harmonious society: the narrow coverage of public health guarantee and the damage to the equality of medical treatment, the fragility of public health guarantee system and the declining of the government’s function, the extraordinary rise of medical cost and unreasonable criteria of evaluating medical efficiency, the high medical expenses and the lack of effective resolution to bad medical ethics and behaviors, the chaos of medical market and the conflict between doctors and patients, the deviations of the government’s path to regulate medical organizations, the worsening of exterior environment of citizen’s health guarantee,etc. Facing the present troublesome situation of our national public medical treatment and sanitation reform, some people believe that the main cause is the incomplete marketability of medical treatment and sanitation, so we need to speed the reform of marketability and let market mechanism function more completely so as to get out from the present difficult situation. Can the medical treatment and sanitation field get more progress following the idea of the reform? Is marketability is the only solution to solve all the problems which appeared? This dissertation through both the theoretical and the empirical analysis and studies gets a different conclusion.I the general idea and structureThe whole dissertation falls into 5 chapters with the following main ideas and basic viewpoints:Chapter One, theoretical analysis of medical treatment and sanitation and governmental intervention. This chapter is mainly divided into two parts. The first part theoretically demonstrates whether the medical treatment and sanitation can be provided in term of the market rules which include the attribute and classification of medical treatment and sanitation, market failure in medical service and the necessity of the governmental strong intervention. The second part demonstrates the dialectic relationship between the guarantee system of medical treatment and economic and social development.Chapter Two, international comparision and revelation of the reform of public medical treatment and sanitation guarantee system from the international perspective. In the developed countries which carry out market economy,social public medical treatment and sanitation guarantee systems of different ranges and levels have been generally formed from the end of the 19th century to the middle of the 20th century. This chapter probes into the medical treatment guarantee system of western societies and mainly focuses on the guarantee system pattern of Britain’s general social medical treatment, part of American medical treatment guarantee and Singapore’s health guarantee fund. British and American public sanitations which are paid much importance by the governments have relatively complete law system and operating mechanism. Their concerning government units have quick response, good cooperation and take charge of their own duties.Chapter Three, retrospection and reconsiderations of public medical treatment and sanitation guarantee system since the establishment of the New China. During the 30 years from 1952 to 1982 when our country was still under the condition of poor financial situation and low general investment into medical treatment and sanitation, our people’s average life span has increased from 35 years old to 68 years old, and baby’s death rate has decreased from 250‰to 40‰and malaria attacks from 5.5% to 0.3%. Before the opening reform, our government-dominated medical treatment and sanitation guarantee system accords with objective rules, and our governmental intervention in choosing the way to develop medical treatment and sanitation career also tallies with objective rules. Since the opening reform, the system has come into the market, resulting in choosing the wrong reform path. Besides, the exterior environment of social public health guarantee is not optimistic, so the public sanitation would face big challenges.Chapter Four, the innovation train of thought of our national public medical treatment and sanitation guarantee system. Facing the trouble situation of our medical treatment and sanitation guarantee system, the central government and theoriticic field attach great importance to it and actively seek new reform ideas and countermeasures. The general thoughts of perfecting our national public medical treatment and sanitation guarantee system are the following two points: one is to reestablsh the government-oriented medical treatment and sanitation guarantee system; another is to separate medical treatment and sanitation. The government would be responsible for public sanitation while medical treatment would continue to move into the direction of maketablity reform. Suqian medical reform embodies a concentrated reflection of the second idea. From both our national and international expericence, we can see that the second reform idea violates the basic development regulations of medical treatment and sanitation and would put our reform into a more troublesome situation.Chapter Five, the research of our national double public medical treatment guarantee system. The realization of the double general medical treatment guarantee system is the aim of the reform. The problem which comes first is how to keep it run effectively and how to guarantee the outlay. It researches the operation of compulsive general social medical treatment. The first is the operation transitional double compulsive general social medical treatment guarantee system; the second one is the compulsive general social medical treatment guarantee system in the harmonious society. The chapter also discusses and designs the operation mechanism of general social medical treatment guarantee’s organizing and management and some preconditions of making it function effectively.II the main innovative viewpointsThe dissertation has the following innovative viewpoints:1. Designing our nation’s pattern of general social medical treatment guarantee. (1).Double compulsive general social medical treatment guarantee pattern. This pattern consists of Part A and Part B. Part A is the pattern of general social medical treatment guarantee for the town people. Part B is for the country people. In Part B, volunteering taking part in the countryside cooperative medical treatment has been changed into compulsive attendance. (2).compulsive general social medical treatment guarantee pattern in the harmonious society. Under the precondition that dual economic structure and dual social structure have been almost eliminated, all the Chinese citizens should perform social medical treatment guarantee system in the light of the uniform layout and standards and combine the transitional double general Medicare pattern A with pattern B.2. Developing the meaning of public sanitation. The paper puts forward the meaning of public sanitation in a broad sense, including direct and indirect public sanitation and their corresponding policy suggestion.3. International perspective of the reform of public medical treatment guarantee system. Through probes into the medical treatment guarantee system of western societies and mainly focuses on the guarantee system pattern of Britain’s general social medical treatment, part of American medical treatment guarantee and Singapore’s health guarantee fund. We should lead to establish general social medical treatment guarantee system in our country.4.Innovating the choices of the path to increase financing input to the health guarantee for the population under the poverty. The financing payout items should be put in an order and advanced step by step according to financing situation. The choices of the path of the health guarantee for the population under the poverty are: providing them with government’s food ticket→improving quality of drinking water and air and increasing financing support for pubic sanitation prevention→providing them government’s medical treatment ticket.5. Designing the special Medicare tax system and innovating managing mechanism of general social medical treatment. The paper designs the special tax system for Medicare. The core of the operation mechanism for management is to manipulate the behaviors of hospitals and doctors to control the cost of medical treatment through general social Medicare. The cost will be supervised by carrying on the budget of total amount for the hospital and government employee system for the doctor. There is no connection between hospitals and doctors’income and medical treatment expenses. Income and expenses become two different lines. Scientific criteria should be set up to evaluate hospital and doctor, and the approach of both qualitative and quantitative analysis should be adapted to scientifically evaluate public hospitals and doctors.

【关键词】 医疗卫生； 公共品； 公共财政； 全民社会医疗保障；

【Key words】 medical treatment and sanitation； public goods； public finance； general social medical treatment guarantee；