建立分级诊疗制度的动力与阻力分析——基于利益相关者理论

分级诊疗体系的构建和运行涉及到医疗卫生服务的需求方、供给方、管理方和筹资方等多个利益相关方。各利益相关方的利益诉求、政策影响力和执行意愿各异,在建立分级诊疗制度的过程中发挥着不同程度的推动或阻碍作用。本文从利益相关者的角度深入分析分级诊疗,认为卫生部门和医保部门是建立分级诊疗制度的主要推动力量,但二者在实施路径上存在差异;财政、发改(物价)等部门的协调配合是分级诊疗顺利推进的必要条件;基层医疗卫生机构的管理者和医务人员是分级诊疗的重要推动因素,但前提是要对相关体制机制进行深层次改革;医院的管理者和医务人员在分级诊疗中利益受损的可能性较大,是政策推行的主要阻碍因素,但二者的阻碍程度不同;居民/患者本应是分级诊疗的重要受益者,但若政策运行不畅、引导措施不当,也有可能成为阻碍因素;医药器械商选择性地参与部分环节,有望成为推动分级诊疗的支持力量。

Analysis on the impetus and resistance to tiered health care system:Based on the stakeholders theory

The establishment and operation of tiered health care system involves multiple health care organizations and individuals comprising the demand, supply, management and financing sides, and other parties. Stakeholders have different interest requirements, policy influences and its implementation willingness, playing at different stages as impetus or obstruction to the establishment of tiered health care system. Analyzing the tiered health care system from the stakeholders'' perspective, this paper considers that health and health insurance sectors constitute the major driving forces and play an irreplaceable role. The financial sector coordinated with the development and reform sector (price sector) make an essential condition for a smooth promotion of tiered health care system. Primary health care institution administrators and medical staff stand for essential motivating factors of a strong tiered health care system. When the premise is to reform the relevant systems and mechanisms, hospital administrators and medical staff may constitute the key obstacles to the implementation of the policy because they are more likely to lose benefit. Meanwhile, the levels of obstruction are different from the both sides; residents and patients are ultimate beneficiaries of the tiered health care system, but can also be the obstructive factors if the policy doesn''t work properly or the when propaganda and guidance are not effective. By selectively participating in part of the service link, the medical equipment suppliers are expected to be the positive impetus to the promotion of tiered health care system.