上海医生人力资源区域分布公平性及影响因素研究

发布时间：2018-01-07 04:07

  本文关键词：上海医生人力资源区域分布公平性及影响因素研究　出处：《上海社会科学院》2017年博士论文　论文类型：学位论文

  更多相关文章： 医生 人力资源 分布 公平性 影响因素

【摘要】：医生人力资源合理配置是满足群众基本医疗服务需求的关键问题,实现医生人力资源合理配置的一个重要方面,是客观分析配置的公平性及其影响因素。本研究从医生人力资源的经济学特征入手,提炼国内外对医生人力资源调控的主要做法和医生人力资源需求测算的主要方法,运用Gini系数、Theil指数、地理信息技术、面板数据模型等技术分析手段,对上海医生人力资源区域分布的公平性及其影响因素开展分析,逐层深入地回答了以下问题:①医生人力资源为什么要公平分布,公平分布的具体要求是什么;②上海医生人力资源区域分布的公平性现状究竟如何;③对医生公平分布的影响因素有哪些,哪些影响是正向的,哪些是负向的;④需要怎么样的政策制度安排,才能抵消负向影响因素、强化正向影响因素,进而促进公平性。本研究通过理论与实际相结合,定性和定量相结合的方法,分析医生人力资源分布的内在规律和目前现状形成的政策根源,以期为推动医生人力资源区域公平分布提供有益的建议。全文分为引言和六个章节。引言部分,点明了选题背景和意义、研究思路和内容、研究方法和技术路线、研究的创新之处和数据来源等。第一章,梳理本研究涉及的主要经济学理论。主要涉及四方面理论。一是人力资本和人力资源的理论。分析了人力资本的特点、人力资源和人力资本之间的内在逻辑联系,从宏观和微观两个角度梳理了人力资源配置所需考虑的因素。指出医生人力资源具有人力资本的特点,包括具有较高的投入成本,可调节、可激励,其价值存在个体差异且可变化等。二是卫生经济学理论。阐述了医疗卫生服务有别于一般商品市场的特点,从理论上、以及发达国家和地区的政策实践探讨政府和市场在医疗资源配置中的作用,对政府的主要医疗卫生职能进行提炼,指出作为卫生资源,医生人力资源配置应具备一定公平性,由于引致需求导致医生动机直接影响医疗服务绩效、外部性等原因导致医生人力资源价格机制部分失灵,因此需要政府进行适当干预。三是制度经济学理论。从我国医疗卫生管理制度的变迁入手,结合制度经济学理论,指出政府提出的宏观社会目标,要与对医疗机构和相关个人的微观激励机制相一致,只要这样才能达到事半功倍的效果,政府干预才能产生显著效果,否则将只能是事倍功半。四是公平理论。从经济社会公平的经典理论和医疗卫生公平性的具体内涵入手,分析医疗资源配置的公平性要求,并阐述了公平性的主要评价方法。第一章内容所涉及的理论和评价方法是后文各章节研究分析的基础,并为结论和政策建议提供理论支撑。第二章,提出研究的总体设计。首先,以医生的卫生资源和人力资本双重属性为理论起点,针对上海推动医生人力资源区域公平分布的政策调控实践,在"医生人力资源公平分布宏观政策目标的实现需要相应的微观激励支持"的总体假设下,提出三个层次的具体研究假设。第二,论述了医生人力资源分布公平性的含义及常用的测度方法。特别指出,不同级别的医疗机构由于功能定位不同,相应的医生人力资源分布的公平性要求也有所不同。第三,综合市场和政府对公平性的影响、学界观点、医生人力资源预测所用到的指标变量等三个方面,梳理医生人力资源区域分布的各影响因素,其中可量化的影响因素有人口和区位状况、区域经济发展水平、卫生经费状况、医疗基础设施布局状况、医疗服务需求、医生经济回报等。第四,开展医生人力资源区域分布影响因素分析的回归模型设计,为实证研究奠定基础。第三章,开展上海医生人力资源区域分布公平性的实证研究。采取逐层深入的方法。首先,分析总的医生人力资源在上海各区县间分布的公平性,以及城乡差异对公平性的影响。其次,根据医疗机构的不同功能定位,依次对剔除三级甲等综合医院和三级专科医院医生后的医生分布公平性情况和社区卫生服务中心医生分布公平性情况及城乡差异的影响进行分析,并对三类情况的分析结果予以比较。第三,针对人均社区卫生服务中心医生数按区县分布基尼系数(Gini系数)测算结果与调查获得的主观感受存在差异的情况,进一步对人均社区医生数以街道和乡镇为单位开展分布的Gini系数分析,并利用地理信息技术,发现不同区域间社区医生服务可及性仍有较大差异。第四,对剔除三级甲等综合医院和三级专科医院医生后的医生分布和社区卫生服务中心医生分布的公平性,经人力质量调整后,再次进行分析,并对调整前后的结果进行比较。第五,对全国整体情况予以分析,并与上海情况进行比对。研究发现,从医生全口径分析、到剔除三级甲等综合医院和三级专科医院医生分析、再到社区卫生服务中心医生分析,Gini系数呈现逐步向好趋势,同时城乡差异对不公平性的影响逐步变小;按街道和乡镇为单位计算社区卫生服务中心医生分布的不公平性,较之按区县为单位计算社区卫生服务中心医生分布的不公平性,Gini系数明显上升,从0.100升至0.232;按职称调整医生人力质量后,不公平程度比调整前有所增加;从医生在全国各省市的分布看,公平性较好且有进一步向好趋势,从趋势上看,上海社区医生在区县的分布与之类似。第四章,开展上海医生人力资源分布影响因素实证分析。基于第二章的研究,从人口和区位状况、区域经济发展水平、卫生经费状况、医疗基础设施布局状况、医疗服务需求、医生经济回报等六方面选取解释变量,构建面板数据模型,得到全国医生人力资源、上海市区级医院医生人力资源、上海市社区卫生服务中心医生人力资源分布的影响因素,比较三者间影响因素的差异。根据面板数据回归分析结果,通过逐一分析各解释变量对医生公平分布的作用方向和机制,分析影响因素与公平性结果间的逻辑关系,得到启示包括:推动医生人力资源区域分布公平需要政府干预;政府对部分影响因素的干预已经产生了效果;但干预需要更多地考虑如何产生正向的激励作用。第五章,从经济学角度对医生人力资源分布的公平性及其影响因素实证分析结果进行相关政策探讨。影响因素可分为可量化因素和不可量化因素两类。面板数据回归模型中所使用到的变量均为可量化的,然而,还有一些政策影响较难直接量化。本章重点从政策溯源的角度,结合经济学理论,分析医生人力制度沿革对影响因素、公平性的作用。首先指出,我国长期以来形成的公立医疗机构人事分配制度,造成不同级别、不同区域医疗机构间医生薪酬差距不断扩大,不利于医生人力资源的公平分布。其次,当前社区卫生服务中心无论是薪酬激励还是职业前景等非薪酬激励都不利于吸引优秀医生。第三,从正外部性的角度,探究了基层医疗卫生机构和郊区农村机构与三、二级医院相比薪酬天然偏低的原因,指出,现有政策强化了外部性造成的基层医疗卫生机构和三、二级医院之间、不同医疗机构之间医生薪酬收入的差距,从而强化了医生人力资源分布的不公平性。比较了公平理论中的庇古津贴和制度经济学中的产权交易理论两种方法在化解外部性时的优劣,提出政府补贴,并运用市场机制的思路。第六章,是主要结论和政策建议。主要结论指出:上海医生人力资源区域分布的公平性状况并未达到政策预期,医生分布与经济发展水平及医疗服务需求存在关联,医疗基础设施的设置布局对医生人力资源区域分布具有正向影响,薪酬激励对医生人力资源区域分布具有正向影响,上海微观激励举措运用较少不利于推动医生区域分布公平性政策目标的实现。提出政府规划引导医生人力资源合理流动、薪酬体系优化医生人力资源空间分布、多重激励调动基层医生积极性、多点执业推动医生人力资源柔性分布等四方面政策建议。
[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.

【学位授予单位】：上海社会科学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R197.1
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本文编号：1390901