社区卫生服务举办主体多元化与政府主导权被迫让渡的关系

目的:社区卫生服务机构中约有半数不属于政府直接举办,形成了多元化的举办主体格局。本文用定性研究的方法审视"举办主体多元化"对社区卫生发展的影响,并探讨监管权解决方案。方法:在陕西省T区和山东省X区,用最大差异抽样法选取不同专业的卫生技术人员以及卫生行政人员进行访谈。采用归纳式的主题分析方法,解释举办主体多元化格局形成的前因后果,并提炼出实务理论。结果:选择举办主体多元化是财力不足、体制约束和卫生资源多样化基础上的适应性策略。这一方面促进了服务网络的建立,另一方面政府被迫让渡主导权给举办主体,社区卫生服务机构缺乏自主管理,监管碎片化、监管弱化,最终社区卫生发展出现偏差。结论:多元举办主体格局的问题实质是治理权划分的问题。解决发展偏差、收回政府主导权的方法应是强化服务监管,放弃对机构的人、财、物等具体事务的管理,同时调整价格、医保等财务相关政策,使社区卫生服务机构具有独立经营能力。

Multi-ownership of community health services and the transferred government leadership in China

Objective: About half of Community Health Services (CHS) in China are not government-owned, forming a multi-ownership situation of CHS. This study aims to examine the effect of "multi-ownership policy" on the development of CHS and put forward suggestions for improving the governance of CHS. Methods: We applied maximum variation sampling to select health workers of different CHS specialties and administrators from local health bureaus in District T of Shaanxi province and District X of Shandong province. Inductive thematic analysis was utilized to interpret the development and ramification of multi-ownership policy, and then to formulate substantive theory. Results: The adoption of multi-ownership in two districts was an adaptive strategy based on the limited public finance, institutional restriction of government, and diversity of health resources. This policy promoted the establishment of CHS network, and meanwhile the government''s leadership of CHS development was transferred to multiple owners of CHS, which caused the lack of CHS autonomy, fragmented regulation power and deviated development of CHS. Conclusions: The key problem of multi-ownership situation in CHS development is the problematic partition of governance power. In order to redeem the leadership of CHS development to the local government, it is necessary to strengthen service regulation while to decentralize the facility management power to CHS, to adjust service price, and to deepen medical insurance coverage of CHS to enhance autonomy of CHS.