發(fā)布時(shí)間：2018-01-07 04:07

  本文關(guān)鍵詞：上海醫(yī)生人力資源區(qū)域分布公平性及影響因素研究　出處：《上海社會(huì)科學(xué)院》2017年博士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 醫(yī)生 人力資源 分布 公平性 影響因素

【摘要】：醫(yī)生人力資源合理配置是滿足群眾基本醫(yī)療服務(wù)需求的關(guān)鍵問題,實(shí)現(xiàn)醫(yī)生人力資源合理配置的一個(gè)重要方面,是客觀分析配置的公平性及其影響因素。本研究從醫(yī)生人力資源的經(jīng)濟(jì)學(xué)特征入手,提煉國內(nèi)外對醫(yī)生人力資源調(diào)控的主要做法和醫(yī)生人力資源需求測算的主要方法,運(yùn)用Gini系數(shù)、Theil指數(shù)、地理信息技術(shù)、面板數(shù)據(jù)模型等技術(shù)分析手段,對上海醫(yī)生人力資源區(qū)域分布的公平性及其影響因素開展分析,逐層深入地回答了以下問題:①醫(yī)生人力資源為什么要公平分布,公平分布的具體要求是什么;②上海醫(yī)生人力資源區(qū)域分布的公平性現(xiàn)狀究竟如何;③對醫(yī)生公平分布的影響因素有哪些,哪些影響是正向的,哪些是負(fù)向的;④需要怎么樣的政策制度安排,才能抵消負(fù)向影響因素、強(qiáng)化正向影響因素,進(jìn)而促進(jìn)公平性。本研究通過理論與實(shí)際相結(jié)合,定性和定量相結(jié)合的方法,分析醫(yī)生人力資源分布的內(nèi)在規(guī)律和目前現(xiàn)狀形成的政策根源,以期為推動(dòng)醫(yī)生人力資源區(qū)域公平分布提供有益的建議。全文分為引言和六個(gè)章節(jié)。引言部分,點(diǎn)明了選題背景和意義、研究思路和內(nèi)容、研究方法和技術(shù)路線、研究的創(chuàng)新之處和數(shù)據(jù)來源等。第一章,梳理本研究涉及的主要經(jīng)濟(jì)學(xué)理論。主要涉及四方面理論。一是人力資本和人力資源的理論。分析了人力資本的特點(diǎn)、人力資源和人力資本之間的內(nèi)在邏輯聯(lián)系,從宏觀和微觀兩個(gè)角度梳理了人力資源配置所需考慮的因素。指出醫(yī)生人力資源具有人力資本的特點(diǎn),包括具有較高的投入成本,可調(diào)節(jié)、可激勵(lì),其價(jià)值存在個(gè)體差異且可變化等。二是衛(wèi)生經(jīng)濟(jì)學(xué)理論。闡述了醫(yī)療衛(wèi)生服務(wù)有別于一般商品市場的特點(diǎn),從理論上、以及發(fā)達(dá)國家和地區(qū)的政策實(shí)踐探討政府和市場在醫(yī)療資源配置中的作用,對政府的主要醫(yī)療衛(wèi)生職能進(jìn)行提煉,指出作為衛(wèi)生資源,醫(yī)生人力資源配置應(yīng)具備一定公平性,由于引致需求導(dǎo)致醫(yī)生動(dòng)機(jī)直接影響醫(yī)療服務(wù)績效、外部性等原因?qū)е箩t(yī)生人力資源價(jià)格機(jī)制部分失靈,因此需要政府進(jìn)行適當(dāng)干預(yù)。三是制度經(jīng)濟(jì)學(xué)理論。從我國醫(yī)療衛(wèi)生管理制度的變遷入手,結(jié)合制度經(jīng)濟(jì)學(xué)理論,指出政府提出的宏觀社會(huì)目標(biāo),要與對醫(yī)療機(jī)構(gòu)和相關(guān)個(gè)人的微觀激勵(lì)機(jī)制相一致,只要這樣才能達(dá)到事半功倍的效果,政府干預(yù)才能產(chǎn)生顯著效果,否則將只能是事倍功半。四是公平理論。從經(jīng)濟(jì)社會(huì)公平的經(jīng)典理論和醫(yī)療衛(wèi)生公平性的具體內(nèi)涵入手,分析醫(yī)療資源配置的公平性要求,并闡述了公平性的主要評價(jià)方法。第一章內(nèi)容所涉及的理論和評價(jià)方法是后文各章節(jié)研究分析的基礎(chǔ),并為結(jié)論和政策建議提供理論支撐。第二章,提出研究的總體設(shè)計(jì)。首先,以醫(yī)生的衛(wèi)生資源和人力資本雙重屬性為理論起點(diǎn),針對上海推動(dòng)醫(yī)生人力資源區(qū)域公平分布的政策調(diào)控實(shí)踐,在"醫(yī)生人力資源公平分布宏觀政策目標(biāo)的實(shí)現(xiàn)需要相應(yīng)的微觀激勵(lì)支持"的總體假設(shè)下,提出三個(gè)層次的具體研究假設(shè)。第二,論述了醫(yī)生人力資源分布公平性的含義及常用的測度方法。特別指出,不同級別的醫(yī)療機(jī)構(gòu)由于功能定位不同,相應(yīng)的醫(yī)生人力資源分布的公平性要求也有所不同。第三,綜合市場和政府對公平性的影響、學(xué)界觀點(diǎn)、醫(yī)生人力資源預(yù)測所用到的指標(biāo)變量等三個(gè)方面,梳理醫(yī)生人力資源區(qū)域分布的各影響因素,其中可量化的影響因素有人口和區(qū)位狀況、區(qū)域經(jīng)濟(jì)發(fā)展水平、衛(wèi)生經(jīng)費(fèi)狀況、醫(yī)療基礎(chǔ)設(shè)施布局狀況、醫(yī)療服務(wù)需求、醫(yī)生經(jīng)濟(jì)回報(bào)等。第四,開展醫(yī)生人力資源區(qū)域分布影響因素分析的回歸模型設(shè)計(jì),為實(shí)證研究奠定基礎(chǔ)。第三章,開展上海醫(yī)生人力資源區(qū)域分布公平性的實(shí)證研究。采取逐層深入的方法。首先,分析總的醫(yī)生人力資源在上海各區(qū)縣間分布的公平性,以及城鄉(xiāng)差異對公平性的影響。其次,根據(jù)醫(yī)療機(jī)構(gòu)的不同功能定位,依次對剔除三級甲等綜合醫(yī)院和三級�？漆t(yī)院醫(yī)生后的醫(yī)生分布公平性情況和社區(qū)衛(wèi)生服務(wù)中心醫(yī)生分布公平性情況及城鄉(xiāng)差異的影響進(jìn)行分析,并對三類情況的分析結(jié)果予以比較。第三,針對人均社區(qū)衛(wèi)生服務(wù)中心醫(yī)生數(shù)按區(qū)縣分布基尼系數(shù)(Gini系數(shù))測算結(jié)果與調(diào)查獲得的主觀感受存在差異的情況,進(jìn)一步對人均社區(qū)醫(yī)生數(shù)以街道和鄉(xiāng)鎮(zhèn)為單位開展分布的Gini系數(shù)分析,并利用地理信息技術(shù),發(fā)現(xiàn)不同區(qū)域間社區(qū)醫(yī)生服務(wù)可及性仍有較大差異。第四,對剔除三級甲等綜合醫(yī)院和三級�？漆t(yī)院醫(yī)生后的醫(yī)生分布和社區(qū)衛(wèi)生服務(wù)中心醫(yī)生分布的公平性,經(jīng)人力質(zhì)量調(diào)整后,再次進(jìn)行分析,并對調(diào)整前后的結(jié)果進(jìn)行比較。第五,對全國整體情況予以分析,并與上海情況進(jìn)行比對。研究發(fā)現(xiàn),從醫(yī)生全口徑分析、到剔除三級甲等綜合醫(yī)院和三級�？漆t(yī)院醫(yī)生分析、再到社區(qū)衛(wèi)生服務(wù)中心醫(yī)生分析,Gini系數(shù)呈現(xiàn)逐步向好趨勢,同時(shí)城鄉(xiāng)差異對不公平性的影響逐步變小;按街道和鄉(xiāng)鎮(zhèn)為單位計(jì)算社區(qū)衛(wèi)生服務(wù)中心醫(yī)生分布的不公平性,較之按區(qū)縣為單位計(jì)算社區(qū)衛(wèi)生服務(wù)中心醫(yī)生分布的不公平性,Gini系數(shù)明顯上升,從0.100升至0.232;按職稱調(diào)整醫(yī)生人力質(zhì)量后,不公平程度比調(diào)整前有所增加;從醫(yī)生在全國各省市的分布看,公平性較好且有進(jìn)一步向好趨勢,從趨勢上看,上海社區(qū)醫(yī)生在區(qū)縣的分布與之類似。第四章,開展上海醫(yī)生人力資源分布影響因素實(shí)證分析�；�于第二章的研究,從人口和區(qū)位狀況、區(qū)域經(jīng)濟(jì)發(fā)展水平、衛(wèi)生經(jīng)費(fèi)狀況、醫(yī)療基礎(chǔ)設(shè)施布局狀況、醫(yī)療服務(wù)需求、醫(yī)生經(jīng)濟(jì)回報(bào)等六方面選取解釋變量,構(gòu)建面板數(shù)據(jù)模型,得到全國醫(yī)生人力資源、上海市區(qū)級醫(yī)院醫(yī)生人力資源、上海市社區(qū)衛(wèi)生服務(wù)中心醫(yī)生人力資源分布的影響因素,比較三者間影響因素的差異。根據(jù)面板數(shù)據(jù)回歸分析結(jié)果,通過逐一分析各解釋變量對醫(yī)生公平分布的作用方向和機(jī)制,分析影響因素與公平性結(jié)果間的邏輯關(guān)系,得到啟示包括:推動(dòng)醫(yī)生人力資源區(qū)域分布公平需要政府干預(yù);政府對部分影響因素的干預(yù)已經(jīng)產(chǎn)生了效果;但干預(yù)需要更多地考慮如何產(chǎn)生正向的激勵(lì)作用。第五章,從經(jīng)濟(jì)學(xué)角度對醫(yī)生人力資源分布的公平性及其影響因素實(shí)證分析結(jié)果進(jìn)行相關(guān)政策探討。影響因素可分為可量化因素和不可量化因素兩類。面板數(shù)據(jù)回歸模型中所使用到的變量均為可量化的,然而,還有一些政策影響較難直接量化。本章重點(diǎn)從政策溯源的角度,結(jié)合經(jīng)濟(jì)學(xué)理論,分析醫(yī)生人力制度沿革對影響因素、公平性的作用。首先指出,我國長期以來形成的公立醫(yī)療機(jī)構(gòu)人事分配制度,造成不同級別、不同區(qū)域醫(yī)療機(jī)構(gòu)間醫(yī)生薪酬差距不斷擴(kuò)大,不利于醫(yī)生人力資源的公平分布。其次,當(dāng)前社區(qū)衛(wèi)生服務(wù)中心無論是薪酬激勵(lì)還是職業(yè)前景等非薪酬激勵(lì)都不利于吸引優(yōu)秀醫(yī)生。第三,從正外部性的角度,探究了基層醫(yī)療衛(wèi)生機(jī)構(gòu)和郊區(qū)農(nóng)村機(jī)構(gòu)與三、二級醫(yī)院相比薪酬天然偏低的原因,指出,現(xiàn)有政策強(qiáng)化了外部性造成的基層醫(yī)療衛(wèi)生機(jī)構(gòu)和三、二級醫(yī)院之間、不同醫(yī)療機(jī)構(gòu)之間醫(yī)生薪酬收入的差距,從而強(qiáng)化了醫(yī)生人力資源分布的不公平性。比較了公平理論中的庇古津貼和制度經(jīng)濟(jì)學(xué)中的產(chǎn)權(quán)交易理論兩種方法在化解外部性時(shí)的優(yōu)劣,提出政府補(bǔ)貼,并運(yùn)用市場機(jī)制的思路。第六章,是主要結(jié)論和政策建議。主要結(jié)論指出:上海醫(yī)生人力資源區(qū)域分布的公平性狀況并未達(dá)到政策預(yù)期,醫(yī)生分布與經(jīng)濟(jì)發(fā)展水平及醫(yī)療服務(wù)需求存在關(guān)聯(lián),醫(yī)療基礎(chǔ)設(shè)施的設(shè)置布局對醫(yī)生人力資源區(qū)域分布具有正向影響,薪酬激勵(lì)對醫(yī)生人力資源區(qū)域分布具有正向影響,上海微觀激勵(lì)舉措運(yùn)用較少不利于推動(dòng)醫(yī)生區(qū)域分布公平性政策目標(biāo)的實(shí)現(xiàn)。提出政府規(guī)劃引導(dǎo)醫(yī)生人力資源合理流動(dòng)、薪酬體系優(yōu)化醫(yī)生人力資源空間分布、多重激勵(lì)調(diào)動(dòng)基層醫(yī)生積極性、多點(diǎn)執(zhí)業(yè)推動(dòng)醫(yī)生人力資源柔性分布等四方面政策建議。
[Abstract]:The rational allocation of human resources is a key issue to meet the needs of the masses of doctor of basic medical services, an important aspect to achieve the rational allocation of human resources is the objective analysis of the doctor's equity and its influence factors of configuration. This study from the economic characteristics of human resources of doctors with the main methods of main practice refining regulation of human resources at home and abroad and the doctor the doctor human resource demand estimates, using Gini coefficient, Theil index, geographic information technology, analysis method of panel data model, analysis of equity and its influence factors of the regional distribution of human resources in Shanghai to carry out the doctor, thoroughly answer the following questions: why the doctor layer of human resources to fair distribution, what is the specific requirements fair distribution; the fairness situation of doctors in Shanghai regional distribution of human resources how to influence on the doctor; equally distributed What are the factors which influence is positive, which is negative; the need to arrange what policies to offset the negative impact factors, strengthen the positive factors, and promote fairness. This study through the combination of theory and practice, the method of qualitative and quantitative analysis of the distribution of human resources, doctor the inherent law and present situation of the formation of policy, in order to promote the fair distribution of regional human resources of doctors provide useful suggestions. This paper is divided into the introduction and six chapters. The introduction part shows the background and significance, research ideas and content, research methods and technical route, research innovation and data sources in the first chapter, the main economic theories involved in this study. Mainly involves four aspects. One is the theory of human capital and human resource theory. Analysis of the characteristics of human capital, and human resources The inner logical relation between human capital, from two angles of macroscopic and microcosmic combing the factors to be considered in the allocation of human resources. Human resources has pointed out that the characteristics of doctors of human capital, including high cost, adjustable, can the value of existing incentives, individual differences and changes. The two is health economics the theory describes the medical and health services. The characteristics are different from the general commodity market, in theory, and the effect of policy practice in developed countries and regions of the government and the market in the allocation of medical resources, mainly for medical and health function of government was refined, pointed out that as the health resources allocation of human resources, the doctor should have a certain fairness due to demand, leading to a doctor motivation to influence the medical service performance directly, the external causes such as part of the doctor human resource price mechanism failure, so the need of government Appropriate intervention. Three is the theory of institutional economics. Starting from the change of medical and health management system in China, combined with the theory of institutional economics, points out that the government put forward the macro social goals, to be consistent with the micro incentive mechanism of medical institutions and individuals, so as to achieve a multiplier effect, government intervention can have a significant effect. Otherwise it will only be less effective. Four is the equity theory. Starting from the specific connotation of economic social justice classic theory and the equity of health care and fairness of the allocation of medical resources, and expounds the main methods of equity evaluation theory and evaluation methods. The first chapter is related to the analysis of the foundation sections of the study, and provide theoretical support for the conclusions and policy recommendations. The second chapter puts forward the overall design of the study. First, to the doctor's health resources and human capital Double attribute as a theoretical starting point, to promote Shanghai policy practice of regional human resources fair distribution of the doctor, "doctor in human resources equitable distribution of macro policy objectives to realize the overall hypothesis micro incentive corresponding support", put forward the research hypothesis three levels. Second, discusses the doctor human resource distribution fairness the meaning and measurement. In particular, the medical institutions of different levels due to different functions, the fairness of the distribution of human resources corresponding to the requirements of the doctor is also different. Third, comprehensive market and government influence on the fairness of the academic point of view, the three aspects of human resources used by the doctor predicted variables. The influence of the regional distribution of doctors combing human resource factors, which affect the quantifiable factors are population and location condition, regional economic development level, health expenditure Medical conditions, infrastructure layout, the demand for medical services, the doctor economic returns. Fourth, carry out the design of regression model to analyze the factors affecting the distribution of regional human resources of doctors, and lay the foundation for the empirical research. The third chapter carry out an empirical study on Shanghai doctor fair of human resource distribution. Adopt the method of layer by layer depth. First of all, fairness analysis of total doctor human resource distribution district in Shanghai County, the influence and the difference between urban and rural areas on fairness. Secondly, according to the different functions of medical institutions, to analyze the influence of successively removed three level of first-class comprehensive hospital and three hospital doctor after doctor distribution fairness and community health service center distribution fairness and the difference between urban and rural areas, and analysis of the three kinds of results to be compared. Third, the per capita number of doctors in Community Health Service Center According to the county distribution Gini coefficient (Gini coefficient) calculation results and the investigation of the subjective feelings of the differences, further analysis of the community doctors hundreds of streets and towns per capita as the unit to carry out the distribution of Gini coefficients, and the use of geographic information technology, found in different regions between community doctor services and there are still big differences. On the fourth, the doctor removed three general hospitals and three hospitals after the doctor distribution and community health service center doctor distribution fairness, the human quality adjusted again, carries on the analysis, and the results were compared before and after adjustment. Fifth, to analyze the overall situation of the country, and compared with the situation in Shanghai. The study found the doctor, from the full aperture analysis, doctors removed three general hospitals and three hospitals analysis, to analysis the doctor community health service center, the Gini coefficient is The trend of gradually getting better, while the impact of difference between urban and rural areas on the unfairness and gradually become smaller; according to the streets and towns for the unit community health service center doctor distribution unfairness, than by the county as a unit of community health service center doctor distribution unfairness, Gini coefficient increased from 0.100 to 0.232; according to the title of doctor manpower quality adjustment, unfair degree increased than before the adjustment; from the distribution of doctors in the various provinces and cities nationwide, fairness and further improve the trend, from the trend, the Shanghai community doctors with similar distribution in the county area. In the fourth chapter, carry out empirical Analysis on the influencing factors of human resource distribution in Shanghai doctor. The second chapter is based on the population and geographical situation, regional economic development level, health funding status, medical infrastructure layout, the demand for medical services, medical economic returns six Selection of explanatory variables, constructing a panel data model, obtained the national doctor of human resources, human resources of doctors in Shanghai city hospitals, influencing factors of Shanghai community health service center doctor human resource distribution, the influence factors of the differences between the three groups. According to the results of the regression analysis of panel data, through the analysis of explanatory variables on the fair distribution of doctors the role of direction and mechanism of logic analysis of the relationship between factors and fairness between the results, obtained the enlightenment include: promotion of human resources of doctors regional distribution justice needs government intervention; the government has had an effect on some influencing factors of the intervention; but the intervention needs more consideration on how to produce a positive incentive. The fifth chapter discusses the related the results of empirical analysis of the factors of fairness and its effects on the distribution of doctors of human resources policy from the angle of economics, the factors can be. Can be divided into quantitative factors and non quantifiable factors. Two kinds of panel data regression used to model variables are measurable, however, there are some policy implications that are difficult to quantify. This chapter mainly from the policy perspective, combined with the theory of economics, analysis of the evolution of the doctor human factors, fair the role of public medical institutions. Firstly, the personnel distribution system in our country has formed for a long time, resulting in different levels of medical institutions, doctors salary gap among different regions is expanding, fair distribution of human resources is not conducive to the doctor. The second, the community health service center whether salary incentive or occupation prospects are non salary motivation to attract the excellent doctor. Third, from the positive externality perspective, explores the basic medical and health institutions and rural institutions and three hospitals, two natural low salary compared to the original Because, pointed out that the existing policy to strengthen the grassroots medical and health institutions caused by externalities and three, between the two hospitals, doctors pay the income gap between different medical institutions, thereby strengthening the unfair distribution of the human resources of the doctor. In comparison of the equity theory in Pigou allowance theory in economics and property rights trading system two methods in resolving externalities when the advantages and disadvantages of proposed government subsidies, and the idea of using the market mechanism. The sixth chapter is the main conclusions and policy suggestions. The main conclusions that: Shanghai regional distribution of health human resources in the fairness of the status did not meet the policy expectations, associated with the presence of doctor distribution and level of economic development and the demand for medical services, medical the infrastructure layout has a positive impact on the doctor human resource distribution, incentive compensation has a positive impact on the regional distribution of human resources of doctors, Shanghai micro Incentives to use less and not conducive to promote the regional distribution of doctors fairness policy objectives. The doctor proposed to guide the rational flow of human resources planning, optimization of the salary system of doctor of human resources space distribution, multiple incentives to mobilize the enthusiasm of the doctor at the grassroots level, more practice doctors push the flexibility of human resource distribution in four aspects of policy recommendations.

【學(xué)位授予單位】：上海社會(huì)科學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R197.1
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本文編號：1390901