摘 要
从 2009 年起，为了适应人民日益增长的医疗卫生服务需求，以及解决我国人口老龄化、疾病谱改变、医疗费用高涨、卫生资源不合理分配等问题，我国政府发布了一系列政策文件推行家庭医生政策。家庭医生政策旨在通过基层医疗卫生机构平台，让有全科医疗知识的全科医生为群众提供及时、连续、全面、个性化的签约卫生医疗服务，成为居民的“健康守门人”。国际经验表明，家庭医生政策在疾病预防、康复保健以及节约医疗资源方面都有较为显着的效果。
尽管家庭医生政策有着较高的现实价值，但是其在执行中依然产生了许多的问题，出现执行困境。本文以公共产品理论、新公共服务理论和公共政策执行理论作为理论基础，结合政策文本和各个地方的家庭医生政策实践，研究家庭医生政策执行的困境及其原因，探索化解困境的思路。
研究发现，家庭医生政策在执行过程中主要出现五大困境，即资源不足困境、政策目标实现困境、主体间利益协调困境、家庭医生激励困境、政策的社会认同困境。这些困境具体表现为：第一，家庭医生资源极度匮乏且服务能力不足，政策执行的财力资源也明显不足；第二，家庭医生工作量超负荷，政策目标实现难度较大；第三，医院与基层医疗卫生机构之间争夺患者和人才；第四，家庭医生的公共卫生任务繁重，家庭医生职业吸引力偏低；第五，家庭医生政策的社会认知度与社会接受度较低。造成上述困境的原因主要有以下几个方面：政策本身的缺陷、政策执行监督约束机制乏力、医院与基层医疗卫生机构的利益协调机制不健全、家庭医生激励机制不完善。基于家庭医生政策执行困境和困境产生的原因，化解家庭医生政策执行困境应该从以下几个方面发力：第一，完善家庭医生政策，完善相关配套制度和法律保障，切实提高政策目标的可行性；第二，应着力加强家庭医生队伍建设、增加对家庭医生政策实施的资金支持、促进基层卫生信息化建设以完善政策执行的资源供给；第三，建立绩效评估制度、政府问责制度以完善政策执行的监督约束机制；第四，拓宽医院与基层医疗卫生机构的利益表达渠道，促进分工协作、完善利益分配；第五，通过提高家庭医生的收入水平、社会地位与职业吸引力，完善家庭医生激励机制；第六，加大家庭医生政策宣传力度，丰富宣传内容、扩大宣传渠道、纠正对家庭医生的认识误区。
关键词：家庭医生，政策，执行困境，化解
ABSTRACT
Since 2009, in order to meet the increasing demands of the people for medical andhealth services, and to solve the problems of aging of population, the change of thedisease spectrum, high cost of medical treatment and unreasonable allocation of healthresources, our government has issued a series of policy documents to promote thefamily doctor policy. The family doctor policy aims to provide community residentswith timely, continuous, comprehensive and personalized contracted health careservices through the platform of community health medical institutions, and familydoctors will become the health gatekeeper of the residents. International experience hasproved that the family doctor policy had a more significant effect in disease prevention,rehabilitation health care, as well as saving medical resources.
Although the family doctor policy has a high realistic value, it still has manyproblems in the implementation. Based on the theory of public product, the theory ofnew public service and the theory of public policy implementation. Combines the textof policy with the practice of local family doctor policy, this paper studies thedifficulties and causes of family doctor policy implementation to explore the ways tosolve the predicaments.
The study found that there are five main difficulties in family doctor policy,namely insufficient resources, goal realization predicament, interest coordinationpredicament, doctor incentive predicament and the policy social identity predicament.
These predicaments are manifested in: firstly, eligible family doctors are extremelyscarce, and the financial resources of policy implementation are obviously insufficient;secondly, the number of family doctors is not adaptable to a huge amount of work, andit is difficult to achieve the goal of policy; thirdly, hospitals fight for patients and talentswith primary medical and health institutions; fourthly, the public health task of thefamily doctor is heavy, and the career attraction of the family doctor is low; fifthly, thesocial cognition and social acceptance of family doctor policy are relatively low. Themain reasons for this phenomenon are as follows: The defects of the policy itself, theweak supervision and restraint mechanism of policy implementation, unsoundmechanism of interest coordination between the hospital and the primary medical andhealth institutions, the imperfect incentive mechanism of the family doctor. Based on the predicaments of the implementation of family doctors' policies and the reasons ofthese predicaments, resolving the predicaments of implementing family doctors' policiesshould make efforts in the following three aspects to: firstly, improve the family doctorpolicy, improve the relevant supporting system and legal protection, and improve thefeasibility of the policy objectives; secondly, strengthen the construction of familydoctors, increase the financial support for the implementation of family doctors policies,and promote the construction of basic level health information service to improve thesupply of policy implementation resources; thirdly, establish the system of performanceevaluation and government accountability system to build an effective mechanism ofpolicy implementation supervision and restraint; fourthly, widen the channels of interestexpression in hospitals and primary medical and health institutions to promote divisionof labor and cooperation and improve the distribution of interests; fifthly, improve thelevel of income, social status and professional attraction of family doctors to improvethe incentive mechanism of family doctors; sixthly, strengthen the family doctor policypropaganda, enrich the propaganda content, expand the publicity channels, correct thewrong understanding of the family doctors.
Keywords: family doctors, policy, implementation predicaments, resolve
目 录
第一章 绪论
1.1 选题依据与研究意义
1.1.1 选题依据
1.1.2 研究意义
1.2 国内外研究现状
1.2.1 国内研究现状
1.2.2 国外研究现状
1.2.3 研究述评
1.3 研究思路与研究方法
1.3.1 研究思路
1.3.2 研究方法
第二章 基本概念与理论基础
2.1 基本概念
2.1.1 家庭医生
2.1.2 家庭医生政策
2.2 理论基础
2.2.1 公共产品理论
2.2.2 新公共服务理论
2.2.3 公共政策执行理论
第三章 我国家庭医生政策发展历程及其体系构成
3.1 我国家庭医生政策的发展历程
3.1.1 试点探索阶段（2009-2011 年）
3.1.2 渐进推广阶段（2012-2015 年）
3.1.3 全面实施阶段（2016 以后）
3.2 家庭医生政策体系的构成
3.2.1 资金补偿政策
3.2.2 家庭医生人才政策
3.2.3 家庭医生首诊政策
3.2.4 家庭医生签约服务政策
第四章 我国家庭医生政策执行的困境
4.1 政策执行资源不足困境
4.1.1 家庭医生数量不足
4.1.2 财力资源不足
4.2 政策目标实现困境
4.2.1 家庭医生工作量超负荷
4.2.2 政策执行盲目推进
4.3 主体间利益协调困境
4.3.1 医院与基层医疗卫生机构的患者之争
4.3.2 医院与基层医疗卫生机构的人才之争
4.4 家庭医生激励困境
4.4.1 家庭医生的公共卫生任务繁重
4.4.2 家庭医生职业吸引力偏低
4.5 政策的社会认同困境
4.5.1 社会认知度较低
4.5.2 社会接受度较低
第五章 我国家庭医生政策执行困境的原因
5.1 政策本身的缺陷
5.1.1 政策目标的可行性较低
5.1.2 政策内容欠具体明确
5.2 政策执行监督约束机制乏力
5.2.1 缺乏相关法规保障
5.2.2 家庭医生评价考核机制不健全
5.3 医院与基层医疗卫生机构的利益协调机制不健全
5.3.1 利益表达渠道不畅通
5.3.2 利益分配机制不健全
5.4 家庭医生激励机制不完善
5.4.1 激励方式单一
5.4.2 激励效果不好
第六章 部分国家和地区家庭医生政策的实践经验
6.1 部分国家的家庭医生政策实践
6.1.1 英国家庭医生政策实践
6.1.2 德国家庭医生政策实践
6.1.3 美国家庭医生政策实践
6.2 部分国家和地区家庭医生政策实施经验借鉴
6.2.1 重视家庭医生人才培养
6.2.2 重视卫生服务信息化
6.2.3 健全的家庭医生激励机制
6.2.4 建立合理的转诊制度
第七章 我国家庭医生政策执行困境化解措施
7.1 完善家庭医生政策内容体系
7.1.1 完善家庭医生政策的配套制度
7.1.2 完善家庭医生政策的法律保障
7.1.3 提高政策目标的可行性
7.2 加大政策执行的资源供给力度
7.2.1 加强家庭医生队伍建设
7.2.2 增加对家庭医生政策实施的资金支持
7.2.3 促进基层卫生服务信息化建设
7.3 建立有效的政策执行监督约束机制
7.3.1 建立绩效评估制度
7.3.2 建立政府问责制度
7.4 完善医院和基层医疗卫生机构的利益协调机制
7.4.1 拓宽利益表达渠道
7.4.2 促进分工协作，完善利益分配
7.5 完善家庭医生激励机制
7.5.1 提高家庭医生收入水平
7.5.2 提高家庭医生的社会地位
7.5.3 提高家庭医生的职业吸引力
7.6 加大家庭医生政策宣传力度
7.6.1 丰富政策宣传内容
7.6.2 扩大政策宣传渠道
7.6.3 纠正对家庭医生的认识误区
第八章 结论
致 谢
参考文献
