家庭医生政策执行方式的行为逻辑

本文采用扎根理论,利用2017—2018年上海3家社区卫生服务中心的访谈材料,从执行者行为的微观角度归纳并构建家庭医生如何选择政策执行方式的理论解释。研究归纳了家庭医生相关政策的执行中存在的三类政策执行方式:忠实执行、积极变通和消极变通。这三类政策执行方式因政策与情境契合度(简称契合度)的不同而区分。其中契合度较高时,容易发生忠实执行,即完全忠实于政策设计的执行方式;当政策与情境有不契合时,执行成本升高,出于职责观念和行政压力,执行者首先使用积极变通来降低执行成本,用自由裁量权在操作中对政策作修补和本土化,从而实现政策初衷;消极变通因任务契合度过低且具有强制性而产生,消极变通中出现了目标替代,仅表面应付上级考核指标,降低了执行成本、维护了岗位利益。结论:政策执行方式的行为逻辑可以通过契合度、职责观念、执行成本三个因素得到解释。本文整体、平衡地关注了消极与积极的政策变通,弥补以往研究只关注消极变通的不足;建议应完善决策制度保证基层执行者的决策参与,从而提升决策质量。

Behavioral logic action in choosing modes of policy implementation modes from family doctors

Applying grounded theory, this article aimed to interpret how and why family doctor studio chose different policy implementation modes from a micro-level angle, using unstructured interviews with Shanghai family doctors and community healther workers. We found their modes of policy implementation, which are obedience, positive adaption and negative adaption, chosed by implementers according to the extent of policy-context fit. With obedience, grass-root level implementers do as they are told by policy designer when policy-context fit (fit in short) is high. When the fit is low, implementation cost will be high, thus positive adaption will be chosen out of bureaucratic pressure and obligation wherein implementers use their discretion to localize and fix original plan, in order to fulfill policy intent. Negative adaption takes place when fit is quite low and policy tasks must be done anyhow, in which implementers use goal displacement and forsake policy intent for supervision indices. Therefore tasks are finished in a superficial way, work benefit being protected. The logic of action in choosing different modes of policy implementation can be explained by policy-context fit, obligation and implementation cost from implementer''s perspective. This article not only focused on failure of policy implementation but both positive and negative adaption in policy implementation. It is suggested that decision-making rules be perfected officially to encourage participation of street-level implementers in policy-making.