基于模糊-冲突模型的家庭医生政策执行困境分析

背景　家庭医生签约服务在提高基层服务能力、满足居民就医需求、落实分级诊疗制度等方面发挥了积极作用,但政策执行过程中履约质量不高、居民认可度不高、家庭医生工作积极性偏低等问题逐渐凸显,如何优化和保障家庭医生政策的实施成为基层改革的焦点问题。目的　探讨我国家庭医生政策执行困境,并提出相应的消除路径,以期为完善家庭医生制度提供参考。方法　本文检索自2016年以来,由国务院、国家卫生健康委等部门发布的有关家庭医生的政策文件,并以“家庭医生”为主题词,检索中国知网、万方数据知识服务平台、维普等数据库,剔除重复、无关等文献,最终纳入合格文献1 393篇。同时以2015-2017年《中国卫生和计划生育统计年鉴》、2018年《中国卫生健康统计年鉴》及2018年我国卫生健康事业发展统计公报的相关数据作为定量资料来源。在此基础上,运用模糊-冲突理论,从政策目标和政策手段的模糊性、政策参与主体间的冲突性、政策执行中的支配性因素等方面,对家庭医生政策执行困境进行分析。结果　家庭医生政策的模糊性逐步降低,政策参与主体间的冲突性仍较为显著,主要表现为政府的愿景规划与居民的就医模式存在差距、上下级医院存在利益协同困境、家庭医生对政策认可度不高。同时,政策执行过程由象征性执行向政治性执行转变,支配性因素也由联盟强度转变为权力。结论　家庭医生政策执行情况未达到预期效果,政策目标地区差异性较低、基层服务能力不强、利益分配与补偿机制不健全、法律保障缺失和资源配置不充足等影响政策执行效果。应从调整政策目标和手段、明确各级医疗机构及医务人员间的利益分配和分工协作机制、改善居民签约服务获得感、完善政策的法律保障、调节卫生资源配置结构等角度破除政策执行过程中的困境。

Analysis on Implementation Difficulties of Family Physician Policy Based on Ambiguity-Conflict Model

Background　The contracted family doctor service has played an active role in improving the service capacity at grassroots level,meeting residents' medical needs,and implementing hierarchical diagnosis and treatment system.However,problems such as the low quality of performance,low degree of residents' recognition,and low enthusiasm of family physicians in the course of policy implementation have gradually become apparent.How to optimize and guarantee the implementation of the family physician policy has become the focus of grassroots reform.Objective　To explore difficulties in the implementation of family physician policy in our country and put forward the corresponding elimination paths,with a view to providing reference for the improvement of the family physician system.Methods　This paper retrieved relevant policy documents on family physician issued by the State Council and the National Health Commission from 2016,and searched documents in the China National Knowledge Infrastructure database,Wanfang Data database and VIP database with "family physician" as the key word.Excluding duplicate and irrelevant documents,1 393 qualified documents were finally included.In addition,China Health and Family Planning Statistics Yearbook（2015—2017）,2018 China Health Statistics Yearbook and China's Health and Wellness Development Statistical Bulletin 2018 were served as quantitative data sources.On this basis,this paper analyzed the difficulties in the implementation of family physician policy from the ambiguity of policy objectives and policy means,the conflict between policy participants,and the dominant factors in policy implementation using the ambiguity-conflict theory.Results　The ambiguity of the family physician policy was gradually reduced,and the conflict between the policy participants was still more significant that mainly manifested in the gap between government's vision plan and residents' medical seeking mode,the benefit balance dilemma in the upper and lower hospitals,and the low degree of policy recognition of the family physicians.At the same time,the policy implementation process was transformed from symbolic implementation to political implementation,and the dominant factors were transformed from the coalition strength to power.Conclusion　The implementation of the family physician policy has not achieved the desired effect.The policy implementation effect was affected by the small difference in policy target areas,the weak service capacity at grassroots level,the imperfect benefit distribution and compensation mechanism,the lack of legal protection,and insufficient resource allocation.To solve difficulties in the policy implementation process,it is recommended to adjust policy objectives and means,clarify the benefit distribution and division of labor and cooperation mechanism among medical institutions and personnel at all levels,improve residents' sense of gain from contracted services,improve the legal guarantee of policies,and adjust the allocation structure of health resources.