行动者中心制度主义视角下县域医疗卫生服务整合路径

国家卫生健康委《关于推进紧密型县域医疗卫生共同体建设的通知》(2019年5月)明确了构建县域紧密型医共体(以下简称"医共体")建设的政策目标.从现有的医疗资源分配机制来看,在政策执行过程中,推动县域医共体行动者间的有效互动和协调行动才能顺利达成政策目标,并切实优化医疗资源配置,提升县域医疗服务能力.本文基于行动者中心制...     

基层卫生推进乡村卫生组织一体化的障碍——基于行动者中心的制度主义分析

推进乡村卫生一体化管理是深化医药卫生体制改革中的一项重要举措。然而,全国各地在实施过程中障碍重重,进程并不顺利。对此,本文以乡村卫生组织一体化模式为例,运用行动者中心的制度主义这一理论工具,结合广东省13县（市）关键行动者的现场访谈,从政策制定者、实施者与政策目标对象的互动出发,分析相关行动者的特征、行动者格局和相互间的互动模式,剖析推进的障碍因素,揭示一体化政策实施过程的复杂性。最后,提出从政策资源、财政资金资源和组织资源投入的角度,建立乡村卫生组织一体化推进策略。     

Accounting for institutional change in health economic evaluation: a program to tackle HIV/AIDS and gender violence in Southern Africa

There has been growing interest in the application of institutionalist perspectives in the health economics literature. This paper investigates the institutionalist notion of social value and its use in economic evaluation with particular reference to a program to address HIV/AIDS and gender violence in Southern Africa (IMAGE). Institutions are the rules that govern the conduct between individuals, groups and organisations. Their social value stems from their capacity to reduce the uncertainty in human interactions thereby both reducing transaction costs and, importantly, enabling the initiation and sustainability of various activities (instrumental value). Furthermore, institutions tend to be formed around certain ethical positions and as a consequence, act in binding future decision making to these positions (intrinsic value). Incorporating such notions of social value within a conventional welfare-based measure of benefit is problematic as institutional development is not necessarily consistent with individual utility. An institutionalist approach allows for these additional domains to be factored into economic evaluation. IMAGE is an intervention to reduce gender violence and HIV through microfinance, health education and community development, and involves significant initial investment in institution-building activities, notably through training activities with program staff and community members. The key to employing an institutionalist approach to the evaluation of IMAGE is in understanding the nature of those actions that can be seen as institution-building and determining: (1) the instrumental value of follow-up activities by appropriate amortisation of transaction costs over an horizon that reflects the economies gained from the intervention; and (2) the intrinsic value of any transformation in the community through a cost-consequences approach informed by an a priori conceptual model. This case study highlights how health sector interventions can effect institutional changes and how these are captured within a theory-based economic evaluation framework.     

Factors predisposing to institutionalism

All psychiatric patients staying in hospital-supervised boarding homes, and a random sample of 50 long-stay patients in the wards of the only mental hospital in Newfoundland were surveyed to determine if certain premorbid factors predispose to institutionalism ('institutional neurosis'). Three hundred and twenty-four patients were examined. Low intelligence, poor education and disabilities in hearing, speech, locomotion and manual dexterity, were significantly associated with institutionalism. Extremes of age on first admission, celibacy, low occupational status in the patient, or his father, and visual disability did not prove to be associated with institutionalism. In conclusion: institutionalism may be found among patients in boarding homes; some patients are more susceptible to institutionalism than others; and institutionalism tends to be associated with those biological or social handicaps which affect communication and activity of the patient.     

我国优质医疗资源扩容改革主体行为逻辑和机制优化——基于行动者中心制度主义的分析

优质医疗资源扩容是国家区域协同发展和公共服务均等化的重大战略要求.为实现医疗资源扩容,中央全面深化改革委员会提出建设区域医疗中心这一创新性制度安排;《中华人民共和国国民经济和社会发展第十四个五年规划和2035年远景目标纲要》再次提出"加快建设区域医疗中心".在现阶段,区域医疗中心试点是否得到有效推进是改革亟需关注的问题...