导　　师： 刘家真

学科专业： 120401

授予学位： 博士

作　　者： ;

机构地区： 武汉大学

摘　　要： 健康保障是公民享有的基本生存权利,公立医院作为医疗卫生供给的主导,在维护公众健康和提供医疗卫生服务方面发挥着关键作用。随着计划经济向市场经济体制的转变,医疗卫生政策也在不断的调整,公立医院与公众的利益冲突日益加剧,公立医院应有的公益性在日益淡化,“看病难”和“看病贵”问题日益凸显。本文的第一章在分析医疗卫生事业发展背景的基础上,提出的研究问题是如何构建一个适宜的治理模式来实现公立医院的公益性。研究的理论意义在于发展和完善来利益相关者理论,拓展了公立医院治理理论,并深化了共同治理理论；现实意义在于促进公立医院的公益性回归,为公立医院改革实践提供理论指导,并拓展了共同治理理论的应用领域。对国内外医院治理研究现状进行了综述,并分析了研究的不足,已有研究主要是对公立医院的组织特殊性及公益性价值目标定位不够明确,没有采取系统的全面的方式来建立适宜的治理模式。本研究遵循提出问题、分析问题和解决问题的研究思路,提出了具体的研究结构框架和主要内容,分析了研究的难点,提出了本研究的创新和研究方法。为方便研究的开展,对本研究涉及到的公立医院、利益相关者、公益性、治理模式、共同治理等关键概念进行了界定。 任何研究都需要有理论基石,由于公立医院治理涉及到行政管理学、经济学、政治学等众多方面和领域,为夯实本研究的基础,本文第二章从跨学科的角度研究公立医院的治理,分别以善治理论、博弈理论、公共产品理论、利益相关者理论、公地悲剧理论、委托代理理论、公共管理理论等相关理论为基础,并将这些理论分析与公立医院的治理变革相结合,分析其对公立医院治理的促进作用,尤其是利用公地悲剧理论分析公立医院治理问题及解决机制。这些理论为公立医院的治理提供了理论支撑与借鉴,带来公立医院治理的合理变革,成为构建公立医院共同治理模式的理论基础。 公立医院的公益性价值是其存在的根本,但其公益性价值目标偏离是现实,其原因是多方面的,需要从实证和理论的角度来分析公立医院公益性淡化的主要原因。多重实证研究是本研究的一个特色,客观的确定了目前公立医院公益性淡化的主要原因,为构建适宜的公立医院治理模式提供了现实依据。本文的第三章分析了公立医院公益性评价的必要性,采取德尔菲法建立了公立医院公益性评价三级指标体系,根据指标体系设计调查问卷,建立数据库,采用TOPSIS方法对数据进行统计分析,对调查的12家公立医院的公益性进行客观评价,实证研究结果表明公立医院公益性评价指数较低。结合公益性评价指标,再从实证的角度设计公立医院公益性淡化主要原因的调查问卷,分别从政府、市场和公立医院自身等三个方面来对公立医院公益性淡化主要原因进行调查,通过SPSS17.0软件对问卷数据进行统计分析,同时对公益性淡化主要原因的数据进行比较分析,进一步验证调查研究的客观性。在调查研究的基础上,再从现实的角度分析公立医院公益性淡化的政府失灵、市场失灵和公立医院自身行为失范的具体原因,为构建公立医院共同治理提供了现实依据。 在理论基础和现实依据等两个支撑点的基础上,本研究进一步确立了公立医院治理模式构建的实践经验,亮点是对国内外医院治理模式进行了总结和分类。本文第四章对美国、英国和德国等国外医院治理进行了分析,同时对宿迁、神木和无锡等国内地区的医改典型实践进行了分析,综合国内医院治理和改革实践,本研究将其归纳为为政府主导型、市场主导型和混合型等三种模式,基于的价值理念以提高效率为主,兼顾质量和公平,这也符合目前我国公立医院改革的主流。但是在国内改革实践中,本文认为公立医院的改革取得的成效主要集中于效率的提升,社会效益兼顾的不够,致使公益性弱化的局面无法从根本上扭转,究其深层次原因是公立医院治理模式及机制没有结合公益性价值目标进行与时俱进的系统设计,在已有治理和改革的优劣势分析基础上得出治理失效的原因,主要是治理系统本身的复杂性、治理主体参与度不够以及治理主体之间的目标互逆。 在市场经济背景下,任何改革都涉及到利益格局的调整,公立医院改革也不例外。本研究引入了利益相关者理论和博弈论,特色是从实证和理论的角度对公立医院的利益相关者及其相互之间的关系进行分析,实现公立医院共同治理的利益整合需要。本文第五章以问卷调查的形式从实证的角度确立了公立医院利益相关者,具体包括公立医院管理者、医务人员、患者、医药企业、医保机构、政府各部门、社会公众、社会组织、其他所有制医院等,根据治理的需要对利益相关者进行了分类。由于各利益相关者利益诉求的不同,再次从实证的角度调查分析了各利益相关者的利益诉求,并以此为依据分析了公立医院利益相关者之间的利益博博弈。目前公立医院既有的利益格局是医院、医生和政府处于主导地位,其他利益相关者的利益没有得到应有的重视和兼顾,社会效益无法凸显,这不利于公益性的实现。本研究认为公立医院利益相关者既存在目标的互逆性,但并不存在完全的排他性,各方也存在力量的愿景和合作博弈的基础。本文以此为基点,主张通过政府、市场和社会三方力量的整合来协调和平衡各利益相关者的利益,良好的利益协调机制有利于利益相关者之间达到博弈均衡,进行利益整合,从而实现公立医院的公益性。 利益相关者的合作博弈需要建立一个良好的治理模式和机制,本研究首次从系统论的角度,将公益性、共同治理与公立医院治理变革相结合,各利益相关者以相对平等的地化共同参与公立医院的治理。本文第六章分析了公立医院共同治理的必要性,认为公立医院的共同治理有利于降低代理成本,有利于社会责任和公益性的实现,有利于内外部权力的制衡和协调,有利于内外部关系的稳定和长远绩效的提高。公立医院共同治理的构建原则包括公平与效率兼顾,利益兼顾与公益性主导,内外部治理相结合,剩余索取权和剩余控制权分散对称分布。公立医院共同治理的组成要素包括治理的主体、客体和环境等要索。在共同治理模式下,根据治理的功能和契约关系将其分为内部参与型治理、交易契约型治理和公共契约型治理,分别阐述了每种治理的模式、主体和机制,并分析了公立医院共同治理中各子系统之间的互动机制,形成治理主体、治理客体、治理环境之间的信息交流与互动,内外治理系统相互配合,充分发挥市场和社会治理的力量。公立医院的内外部治理是互动治理的过程,利益相关者可同时参与不同的治理机制并同时发挥应有的作用。 公立医院共同治理模式有效性的发挥依赖于具体的实现路径,将实现路径与公益性价值目标紧密结合,分析了目前实现路径存在的主要问题,并提出了相应的对策建议,其中的创新就是从重构政府规制体系、建立信息强制披露机制和建立公益性评价机制来改善治理的有效性。本文第七章在公益性价值目标分析的基础上,提出了公立医院共同治理公益性价值的实现路径,但其中内部参与型治理的实现路径主要是从完善法人治理机制、健全内部控制体系、建立灵活的用人管理机制和制定合理的薪酬激励机制等方面分析存在的问题及提出相应的措施；交易契约型治理实现路径主要从完善价格形成机制、建立新的医疗保障模式和改革医药生产流通体制等方面分析存在的问题及提出相应的措施；公共契约型治理实现路径主要是从重构政府规制体系、完善外部监督机制、建立信息披露机制、健全改革决策机制、建立公益性评价机制以及强化伦理道德机制等方面分析存在的问题及提出相应的措施；对公立医院共同治理公益性价值实现路径的整合进行了分析,认为政府要从制度层面主导各个治理环节的协调工作,整合共同治理的实现路径,从而保证共同治理模式下公立医院公益性的实现。本文第八章对公立医院共同治理进行了总结,提出了研究的结论,并对未来的研究进行了展望,进一步拓展了可能的研究空间。 Health insurance is the basic right of life which the citizens should enjoy. The public hospital, as the leading medical and health supplier, should play a key role in providing medical and health services. With the transition from the planned economy to the market economy system, health care policies have been adjusted. The conflict of interest between public hospitals and public is becoming more and more serious. The public interest of public hospital is desalination. The problem that medical treatment is difficult and expensive is becoming increasingly prominent. Based on the analysis of the background of medical and health development, the first chapter thinks that the study problem is how to build a suitable governance model for the public hospital in order to achieve public interest, and demonstrates the theoretical and practical significance of this study. The theoretical significance lies in developing and perfecting the stakeholder theory, expanding the governance theory of public hospital, and deepening the common governance theory. The practical significance lies in promoting public interest desalination of public hospital, providing theoretical guidance for the practice of public hospital reform, and expanding the application field of governance theory. Based on the review of domestic and overseas hospital governance, this chapter analyzes the shortcomings of the research and presents the research innovation. The previous studies couldn't make clear on the specificity of public hospital organization and public interest orientation, and did not take the way to establish the suitable governance model. This study follows the research ideas of problem, analysis and solving. As to the study problem, this chapter proposes the research ideas, framework and main content, analyzes the difficulties of the study, and presents the research methods. For the convenience of research, this study presents the key concepts such as public hospital, stakeholder, public interest, common governance. Any research needs to have theoretical foundation. Because public hospital governance relates to public administration, economics and political science, the second chapter studies the public hospital governance from the interdisciplinary perspective. These theories include the good governance theory, game theory, public goods theory, stakeholder theory, the tragedy of the commons theory, principal-agent theory, public management theory and other related theories. These theories provide theoretical support and reference for the public hospital governance. For example, the use of resolution mechanism of tragedy of the commons can apply to public hospital governance. These theories become the theoretical foundation of common governance of public hospital. Public interest of public hospital is the root of its existence, but its public interest goal deviates from the reality. Of course the reasons are many. It is necessary to analyze the main reasons of the public interest desalination from the point of empirical and practical view. The feature of this study is multiple empirical analysis. This study can objectively determine the main reasons of the public interest desalination of public hospital, and provide a realistic basis for the establishment of public hospital governance model. The third chapter analyzes the necessity of the evaluation of the public interest of public hospital, establishes the evaluation index system with three grades by Delphi method. According to the index system design of the questionnaire, the study establishes a database, analyzes the date by the method of TOPSIS, and evaluates objectively the public interest of12public hospitals. The results of this empirical study show that the public evaluation index of public hospitals is low. This study uses the public interest evaluation index and carries on the questionnaire for the government, market and public hospitals in order to study the main reasons of public interest desalination of public hospital. Through the SPSS17.0software this study analyzes the questionnaire data and does comparative analysis to further verify the investigation. On the basis of investigation and research, the study analyzes the public interest desalination of government failure, market failure and incorrect behavior of public hospital from the point of reality. On the two points of theoretical and realistic support, this study further constructs practical experience point of the common governance model of public hospital. The highlights are to summary and classify the governance models of domestic and overseas hospitals. The fourth chapter analyzes the hospital governance of the United States of America, Britain, Germany and Suqian, Shenmu and Wuxi. Bases on the hospital governance reform practice, this study makes these governace models divided into government-led governance, market-led governance and mixed type governance. These governance models can improve efficiency, quality and fairness. The valuse is also consistent with the public hospital reform in China at present. But in the reform practice, the reform achievements of public hospital mainly focus on the efficiency, and the social benefits is not enough. The deep reason is that the design of public hospital governance model and machine system can't be combined with the public interest goa. Based on the analysis of the advantages and disadvantages of existing governance and reform, this study thinks that the main reasons of governance failure include three aspects. For example, the governance system itself is complexity, subject participation is not enough, and governance value goals among the main subjects are inverse. In the context of the market economy, any reform involves the adjustment of interest. The public hospital reform is no exception. This study introduces the stakeholder theory and game theory. The study characteristic is to analyze the relationship among the public hospital stakeholders'interests from the perspective of empirical and theoretical in order to realize the needs of integration of public hospital governance. In the fifth chapter, this study confirms and classifies the stakeholders in the form of questionnaire survey among public hospital stakeholders, including public hospital administrators, medical staff, patients, pharmaceutical companies, health care institutions, government departments, public, social organizations, other ownership hospitals. Due to the different interest pursuits for the various stakeholders, another investigation is carried on to analyze the interest pursuits of the stakeholders. On the basis of this analysis, this study analyzes the game between public hospitals and their stakeholders. At present, the hospital, the doctor and the government is in the leading position. But the interest of other stakeholders can not accept enough consideration, and the social benefits can not be highlighted. This study suggests that the game between the public hospital stakeholders is not the zero-sum game, but the cooperative game. It needs to coordinate the interests through the power of market, government and society. Good interest coordination mechanism benefits to reach game equilibrium between stakeholders and promote the public interest. Cooperative game of stakeholders needs to establish a good common governance model and mechanism. This study is the first time to study the public hospital governance with common governance and public interest from the point of the system. The sixth chapter analyzes the necessity of common governance of public hospital, and thinks this governance can reduce agency costs, realize social responsibility and public interest, balance and coordinate the internal and external power, maintain internal and external relations stable and long-term performance. The principles of common governance include fairness and efficiency, taking into account the interests and welfare, internal and external governance combined, residual control right and residual claim right symmetric distribution. Stakeholders participate in the public hospital governance with relatively equal right. In the common governance, according to the system, the common governance of public hospitals is divided into internal and external governance. The internal governance is internal participatory governance. According to the contract theory, the external governance is divided into contractual governance and public contract management. Internal and external governance of public hospital governance is interactive. Stakeholders can participate in different governance mechanisms and play their role at the same time. The effectiveness of the common governance model depends on the implementation of specific path, and combines the realization path with the public interest goal closely. This study analyzes the main problems existing in the realization path, and puts forward the corresponding countermeasures. The innovations inlcude improving the effectiveness of governance regulation, establishing information disclosure mechanism and public interst evaluation mechanism. The seventh chapter puts forward the realization paths of the common governance of public hospital. The realization paths of internal participatory governance are the establishment of the common governance structure, a sound internal control system, establishment of flexible personnel management mechanism and a reasonable salary incentive system. The realization paths of trading contract governance are the perfect price formation, the establishment of new medical security model and the reform of the pharmaceutical production and circulation system. The realization paths of public contractual governance are the reconstruction of government regulation system, improving the external supervision mechanism, establishing the information disclosure mechanism, reforming decision-making mechanism of public hospital, establishing public interest evaluation mechanism and strengthening the ethical mechanism. The government should lead the coordination from the system level, integrates the paths of governance to ensure the realization of the public interest of public hospital governance. The eighth chapter summaries the common governance of public hospital and the future research prospects.

关 键 词： 公益性 公立医院 利益相关者 共同治理

分 类 号： [D630.1]

领　　域： [政治法律] [政治法律]